Tuberculosis Stigma Research Articles

Towards TB Elimination in Aotearoa/New Zealand: Key Informant Insights on the Determinants of TB among African Migrants.

Migrants living in low incidence countries, including New Zealand (NZ), are disproportionately affected by tuberculosis (TB). This foreign-born group poses important challenges to achieving the national TB elimination targets. Thus, the aim of this study was to contribute to the understandingof factors that influence the incidence of TB among African migrants living in NZ. We employed a semi-structured interview approach to explore the perceptions of NZ-based African community leaders, health professionals and a non-governmental TB support organisation about the wider determinants of TB. The findings, though not completely generalizable, suggest that many NZ-based Africans endure a difficult process of integration, perceive themselves as least susceptible to TB and have low awareness about available health services. Furthermore, the cost of general practitioner (GP) services, mistrust of health professionals, TB stigma and the NZ immigration policy were indicated as important barriers to TB services. Strategies to address TB among migrants must therefore be more holistic and not be centred on a fragmented approach that overemphasises the biomedical approaches, as the incidence of TB is more likely the outcome of a complex interplay of several underlying factors.

Measuring HIV- and TB-related stigma among health care workers in South Africa: a validation and reliability study.

Recent evidence indicates that human immunodeficiency virus (HIV) and tuberculosis (TB) related stigma act as a key barrier to the utilisation of associated occupational health services by South African health care workers (HCWs). It also highlights a dearth of appropriate tools to measure HIV and TB stigma among HCWs. To test four scales measuring different aspects of stigma: respondent's external stigma (RES) and others' external stigma (OES) towards TB as well as HIV across different professional categories of HCWs. The current study employs data from a study on HIV and TB stigma among HCWs, a cluster randomised controlled trial for the collection of data among 882 HCWs in the Free State Province of South Africa. Confirmatory factor analyses and structural equation modelling were used to assess the validity and reliability of the scales. All four scales displayed adequate internal construct validity. Subsequent analysis demonstrated that all four scales were metric-invariant, and that the OES scales were even scalar-invariant across patient and support staff groups. The scales displayed good reliability and external construct validity. Our results support the use of the scales developed to measure TB and HIV stigma among HCWs. Further research is, however, needed to fine tune the instruments and test them across different resource-limited countries.

Using 15 DHS surveys to study epidemiological correlates of TB courtesy stigma and health-seeking behaviour.

Tuberculosis (TB) stigma is thought to delay or prevent the decision to seek health care, but the strength of this association and the prevalence of anticipated TB stigma in the general population in most countries is unknown. To examine epidemiological, cultural and sociodemographic factors associated with TB courtesy stigma in 15 surveys across 13 countries, and its link to health seeking for cough in children under five. A multilevel survey weighted logistic regression model was used to analyse how individual characteristics and social contexts affect the occurrence of TB courtesy stigma. The same modelling approach was used to analyse associations between TB courtesy stigma and individual-level predictors of health-seeking behaviour of mothers for children with cough. TB courtesy stigma varies greatly among countries. TB courtesy stigma was negatively correlated with knowledge of TB's curability (adjusted OR [aOR] 0.82; 95%CI 0.78-0.86) and human immunodeficiency virus (HIV) accepting attitudes (proxy for HIV stigma) (aOR 0.15, 95%CI 0.15-0.16). Mothers' health-seeking behaviour for children under five with cough was found to be positively correlated with HIV accepting attitudes (OR 1.16, 95%CI 1.08-1.25), but was marginally affected by TB courtesy stigma (OR 0.99, 95%CI 0.98-1.00). Improving the general awareness of the effectiveness of anti-tuberculosis treatment will help to diminish TB courtesy stigma, and should be prioritised over expanding knowledge of mode of transmission. Efforts to reduce HIV and TB stigma may increase care seeking for childhood TB symptoms.

Defining the research agenda to measure and reduce tuberculosis stigmas

Crucial to finding and treating the 4 million tuberculosis (TB) patients currently missed by national TB programmes, TB stigma is receiving well-deserved and long-delayed attention at the global level. However, the ability to measure and evaluate the success of TB stigma-reduction efforts is limited by the need for additional tools. At a 2016 TB stigma-measurement meeting held in The Hague, The Netherlands, stigma experts discussed and proposed a research agenda around four themes: 1) drivers: what are the main drivers and domains of TB stigma(s)?; 2) consequences: how consequential are TB stigmas and how are negative impacts most felt?; 3) burden: what is the global prevalence and distribution of TB stigma(s) and what explains any variation? 4): intervention: what can be done to reduce the extent and impact of TB stigma(s)? Each theme was further subdivided into research topics to be addressed to move the agenda forward. These include greater clarity on what causes TB stigmas to emerge and thrive, the difficulty of measuring the complexity of stigma, and the improbability of a universal stigma 'cure'. Nevertheless, these challenges should not hinder investments in the measurement and reduction of TB stigma. We believe it is time to focus on how, and not whether, the global community should measure and reduce TB stigma.

TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi.

Urban Blantyre, Malawi. To understand why men with tuberculosis (TB) in the community remain undiagnosed. A multi-method qualitative study applying a modified grounded theory approach. Data were gathered from March 2011 to March 2012 from 134 men and women taking part in 1) focus group discussions with community members (n = 6) and health care workers (n = 2), and 2) in-depth interviews with TB patients (n = 20, females n = 14) and chronic coughers (n = 20, women n = 8). Data were analysed inductively to identify, refine and consolidate, and verify emerging concepts and themes. Two emerging themes highlighting compound stigma in this high human immunodeficiency virus (HIV) prevalence, low-income setting are presented. First, cough or any illness that portended a 'serious' condition were accompanied by portrayals of cough, TB and HIV as being interchangeable. Chronic coughers and TB patients described their illness in ways that foregrounded bodily decimation and rupture of social life and masculine identity. Second, 'resistance strategies' entailed resisting classification as (seriously) ill by evading or ambivalently approaching health care, or acknowledging the 'ill' status then actively pursuing health-appropriate behaviours, including changing lifestyle or adopting non-normative gender roles. Managing patients requires 1) going beyond syndromic management based on vital signs and clinical indicators to recognising and intervening on health care-seeking related tensions to retain individuals in care, and 2) understanding and addressing TB stigma as it manifests and affects men and women differently in specific settings.

Stigma as a barrier to the use of occupational health units for tuberculosis services in South Africa.

Tuberculosis (TB) is the leading cause of death in South Africa, and health care workers (HCWs) are disproportionally affected. The resulting absenteeism strains the already overburdened health system. Although hospital occupational health care units (OHUs) are cost-effective and of crucial importance in tackling the TB epidemic, the fear of being stigmatised by other colleagues might lead HCWs to avoid using OHUs. To investigate whether the perception of TB stigma among colleagues has a negative effect on the willingness to use OHUs for TB services. In the Free State Province, South Africa, a representative sample of 804 HCWs from six hospitals were surveyed on workplace stigma as a predictor for the use of OHUs for TB services. Applying structural equation modelling, we also controlled for exogenous variables. There was a significant negative relationship between the perception of stigmatising attitudes and behaviours among co-workers and the use of OHUs for TB screening (β -0.21, P = 0.000), treatment (β -0.16, P = 0.001) and isoniazid preventive therapy (β -0.17, P = 0.000). The negative effect of TB stigma on OHU use among HCWs can impact upon their health and increase hospital costs. This needs to be addressed by interventions combating TB stigma among HCWs in the workplace.

'It makes the patient's spirit weaker': tuberculosis stigma and gender interaction in Dar es Salaam, Tanzania.

Dar es Salaam, Tanzania. To describe tuberculosis (TB) related stigma and to understand how it interacts with gender to affect access to care. Eight focus group discussions were held among 48 TB patients and their household members, and a thematic content analysis was carried out. The main components of stigma were fear, self-isolation, ostracization, loss of status in the community, and discrimination by providers. Participants described the cultural context in which stigma operated as characterized by a general lack of health knowledge, cultural beliefs about TB, and engendered beliefs about disease in general. Both genders described some similar effects of stigma, including relationship difficulties and specifically challenges forming new relationships, but many effects of stigma were distinct by gender: women described challenges including assumptions about promiscuity and infidelity, as well as rejection by partners, while men described survival challenges. Stigma acted as a barrier to care through a cyclical pattern of stigma and fear, leading to health-seeking delays, with resulting continued transmission and poor health outcomes that further reinforced stigma. TB-related stigma is prevalent in this setting and operates differently for men and women. Interventions designed to increase case detection must address stigma and its interaction with gender.

Depressive symptoms and hazardous/harmful alcohol use are prevalent and correlate with stigma among TB-HIV patients in Lesotho.

Limited data exist on the prevalence and correlates, including stigma, of mental health conditions, including depressive symptoms and alcohol use, among patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) in sub-Saharan Africa, despite their negative impact on health outcomes. To assess the prevalence and correlates of depressive symptoms and hazardous/harmful alcohol use among TB-HIV patients in the Start TB patients on ART and Retain on Treatment (START) study. START, a mixed-methods cluster-randomized trial, evaluated a combination intervention package vs. standard of care (SOC) to improve treatment outcomes in TB-HIV co-infected patients in Lesotho. Moderate/severe depressive symptoms and hazardous/harmful alcohol use were measured using baseline questionnaire data collected from April 2013 to March 2015. Demographic, psychosocial, and TB- and HIV-related knowledge and attitudes, including stigma, were assessed for association with both conditions using generalized linear mixed models. Among 371 participants, 29.8% reported moderate/severe depressive symptoms, and 24.7% reported hazardous/harmful alcohol use; 7% reported both. Depressive symptoms were significantly associated with less education, more difficulty understanding written medical information, non-disclosure of TB, greater TB stigma, and the SOC study arm. Hazardous/harmful alcohol use was significantly associated with male sex, as well as greater TB and external HIV stigma. Prevalence of depressive symptoms and hazardous/harmful alcohol use were high, suggesting a need for routine screening for, and treatment of, mental health disorders in TB-HIV patients.

ADAPTING A STIGMA SCALE FOR ASSESSMENT OF TUBERCULOSIS-RELATED STIGMA AMONG ENGLISH/SWAHILI-SPEAKING PATIENTS IN AN AFRICAN SETTING.

To adapt a validated instrument that quantitatively measures stigma among English/Swahili speaking TB (tuberculosis) patients in Kenya, a high burden TB country. Following ethical approval, we elicited feedback on the English and Swahili translated Stigma Scale for Chronic Illness (SSCI) tools through cognitive interviews. We assessed difficulties in translation, differences in meaning, TB contextual relevance, patients' acceptability to the questions, and issues in tool structure. The interviews were audio recorded, transcribed and translated. Open coding and thematic analysis of the data was conducted by two independent researchers. Between May and September 2015 we conducted a qualitative study among 20 adult TB patients attending 11 health facilities in Nairobi County, Kenya. Most questions were understood in both English and Swahili, deemed relevant in the context of TB and acceptable to TB patients. Key areas of adaptation of the SSCI included adding questions addressing fear of infecting others and death, HIV stigma, and intimate, family and workplace relationship contexts. Questions were revised for non-redundancy, specificity and optimized sequence. The adapted 8-item SSCI appears to be a useful tool that may be administered by health workers in English or Swahili to quantify TB stigma among TB patients in Kenya.

Evidence-based interventions to reduce tuberculosis stigma: a systematic review.

While substantial progress is being made in tuberculosis (TB) control, the success of public health efforts is hampered by pervasive stigma. To perform a systematic literature review to assess the effectiveness of interventions aimed at reducing TB stigma in patients, health care workers, care givers and the general community. Studies were eligible for inclusion if they evaluated interventions aimed at reducing TB stigma and were published between 1950 and 2015. We searched eight databases (PubMed, Cochrane Library, Ovid, Embase, PsycInfo, Sociological Abstracts, Cumulative Index to Nursing and Allied Health Literature, World Health Organization Latin American and Caribbean Health Sciences Literature), and complemented the searches by using the snowball strategy and by reviewing relevant grey literature. Only seven studies were identified as providing quantitative (n = 4) or qualitative (n = 3) evidence of effectiveness in reducing TB stigma. Quality assessment of the studies was poor. Knowledge-shaping and attitude-changing interventions aimed at the public, patients and their families were effective in reducing anticipated stigma. Home visits and support groups were effective in reducing both anticipated and internalised stigma. There is a dearth of reliable information on the effectiveness of TB stigma-reduction interventions. Knowledge-shaping, attitude-changing and patient-support interventions can be effective in reducing TB stigma, but more rigorous evaluations are needed.

Secondary analysis of tuberculosis stigma data from a cluster randomised trial in Zambia and South Africa (ZAMSTAR).

Zambian and South African TB and HIV Reduction (ZAMSTAR) cluster-randomised trial (CRT) communities, 2006-2009. To develop TB stigma items, and evaluate changes in them in response to a household intervention aimed at reducing TB transmission and prevalence but not tailored to reduce stigma. TB stigma was measured at baseline and 18 months later among 1826 recently diagnosed TB patients and 1235 adult members of their households across 24 communities; 12 of 24 communities were randomised to receive the household intervention. We estimated the impact of the household intervention on TB stigma using standard CRT analytical methods. Among household members, prevalence of blame and belief in transmission myths fell in both study arms over time: adjusted prevalence ratios (aPRs) comparing the household intervention with the non-household intervention arm were respectively 0.61 (95%CI 0.26-1.44) and 0.77 (95%CI 0.48-1.25) at 18-month follow-up. Among TB patients, at baseline a low percentage experienced social exclusion and poor treatment by health staff and a relatively high percentage reported 'being made fun of', with little change over time. Disclosure of TB status increased over time in both study arms. Internalised stigma was less prevalent in the household arm at both baseline and follow-up, with an aPR of 0.85 (95%CI 0.41-1.76). Variability in stigma levels between countries and across communities was large. Robust TB stigma items were developed. TB stigma was not significantly reduced by the household intervention, although confidence intervals for estimated intervention effects were wide. We suggest that stigma-specific interventions are required to effectively address TB stigma.

Clinical Ramifications of TB Stigma in Baguio City, Philippines

Objective. Stigmatization due to a disease is a complex process, particularly in the case of tuberculosis (TB) in Baguio City, Philippines. This article reveals findings important to healthcare professionals in the outpatient setting. Complex aspects of stigma vary among people and healthcare professionals in different roles and settings, facilitating behavior that controls TB in some cases and spreads it in others. Methods. With ethnographic and historical methods, Ladia analyzed a wide range of understandings of 36 healthcare providers and 14 persons affected by TB (PATB). These understandings shape clinical behavior with significant implications for patient outcomes and community health. TB treatment and control historically established concepts and behavioral patterns that have a significant bearing on public understanding today. Comparisons with national survey data supported the analysis. Results and Conclusions. Sources of varied understandings of TB include the history of sanitaria, poverty, and incomplete dissemination of current scientific information. While some behavior related to stigma could benefit the health of PATB and their household members, the struggle against stigma leads to counterproductive behavior in a number of cases, sometimes spreading disease and sometimes resulting in unnecessary labor and expense. Healthcare providers can provide accurate, accessible, detailed information to address patients’ problems.

Perceived stigma and depression in initially diagnosed pulmonary tuberculosis patients.

To investigate the status of tuberculosis stigma and depression among tuberculosis patients, to examine the relationship between demographics and tuberculosis stigma and depression among tuberculosis patients, and to identify the predictors of depression among tuberculosis patients. After the diagnosis of tuberculosis, patients suffer from disease symptoms and disease-related stigma. Depression is also a major concern in tuberculosis patients. A cross-sectional design was used in this study. A total of 84 subjects, obtained through convenience sampling, enrolled in this study, which was conducted from 1 March 2013-30 December 2014. Data were collected using a structured questionnaire with a demographic component, the Tuberculosis-related Stigma Scale, and the Beck Depression Inventory-II. Data were analysed, using spss Version 20. Independent t tests, Pearson's correlation coefficient tests and analyses of variance were used for analysis of patient demographic characteristics, disease characteristics, and the correlation between stigma and depression. Multiple linear regression was used for determining the predictors of depression. The results showed that not disclosing one's illness to others was associated with tuberculosis stigma and depression. Multiple linear regression analysis indicated that patient-perceived tuberculosis stigma and body mass index accounted for 34% of the variation in depression. These results can serve as a reference for clinical healthcare providers to understand perceived stigma and depression in initially diagnosed tuberculosis patients. An intervention to reduce patient tuberculosis stigma, such as improving community healthcare education or offering mental health outreach, has great potential to lower the level of depression among patients with tuberculosis.

Barriers to tuberculosis care delivery among miners and their families in South Africa: an ethnographic study.

South African miners suffer the highest tuberculosis (TB) rates in the world. Current efforts to stem the epidemic are insufficient. Historical legacies and persistent disease burden demand innovative approaches to reshape health care delivery to better serve this population. To characterize social and behavioral health determinants for successful TB care delivery and treatment from the perspective of miners/ex-miners, health care workers and policy makers/managers. We conducted applied ethnography with 30 miners/ex-miners, 13 family/community members, 14 health care providers, and 47 local policy makers/managers in South Africa. Miners/ex-miners felt health care delivery systems failed to meet their needs. Many had experienced unnecessary physical and psychological harm due to limited health education about TB, minimal engagement in their own care, lack of trust in providers, and a system that did not value their experience. Stigma and fear associated with TB result in denial of symptoms and delays in care seeking. Health care providers and policy makers/managers felt discouraged by system constraints in providing optimal care. Our findings describe long-term effects of perpetual TB misinformation and stigma resulting from fear and disempowerment among miners and their families/communities. To reduce the TB burden, there is an urgent need to co-design a care delivery system with miners to better meet their needs.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa.

The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting. The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa. Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity. The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia.

BackgroundStigma attached to tuberculosis contributes to the limited effectiveness of current TB control approaches. However, there is a dearth of studies that explore the causes of stigma attached to tuberculosis and its effects on patients and tuberculosiscontrol programs in Ethiopia.MethodsAn institution-based qualitative study was conducted at St. Peter Tuberculosis Specialized Hospital in Addis Ababa, Ethiopia from July to August, 2015. Ten in-depth interviews and 6 key-informant interviews were carried out among tuberculosis patients and healthcare workers, respectively.The Open Code computer software package was used to analyze the data thematically.ResultsThe study revealed that fear of infection and inappropriate health education messages by media were the main causes of tuberculosis stigma. The patients experienced isolation within their family and community, separation, and financial crisis. The stigma attached to tuberculosis may contribute to delayed healthcare seeking, poor treatment adherence, and poor prognosis.ConclusionInterventions thatreduce the stigma attached to tuberculosis should target on areas, such as creating community awareness, patient counseling on problem-solving and emotional skills, preparing culturally sensitive and scientifically sound media messages, providing financial support for the patients, and enhancing the qualities of the healthcare workers, such as empathy, concern, respect for the patient and cultural sensitivity.

Engaging adolescents in tuberculosis and clinical trial research through drama.

BackgroundThe South African Tuberculosis Vaccine Initiative is based in Worcester where tuberculosis (TB) is endemic, and incidence rates are amongst the highest nationally. In high TB burden settings after an early childhood peak, incidence rates start to rise again in adolescents, therefore they are an important target group for tuberculosis vaccine research. In 2012, learners from a local school developed a one-off theatrical production out of an educational comic book Carina’s Choice, developed by the South African Tuberculosis Vaccine Initiative in 2010. A Wellcome Trust International Engagement grant allowed for this one-off production to be further developed, with input from university students and staff, and rolled out to schools in the Worcester area as an engagement and education intervention.MethodsFocus group feedback was used to identify key messages and to develop the play’s script. Qualitative methods were used to collect and analyse relevant data. Interviews were conducted with learner-actors, pre- and post-focus group feedback was obtained from a sample of school-going adolescents, and pre- and post-questionnaires were administered to adolescent audience members.ResultsFrom the pre-drama focus group discussions, topics such as TB symptoms, stigma and transmission were identified as areas that needed attention. After the performances, adolescents showed improved knowledge on the identified topics and they discussed TB prevention measures. They highlighted transmission of TB during pregnancy as a further topic to be addressed in future iterations of the drama. Although stigma is a difficult phenomenon to interpret, post-drama participants understood that TB transmission could occur in all individuals. Learner-actors agreed with focus group participants that the play could impact the wider community if it were rolled out. Feedback from the South African Tuberculosis Vaccine Initiative staff verified that recruitment for an upcoming trial was facilitated by the preparedness that the play provided in recruitment areas. The study showed that before and after evaluations provide data on the usefulness of the play as an education tool.ConclusionsTheatre, presented and motivated by adolescent peers, can raise awareness of TB, and assist clinical trial preparedness and further engagement between trial staff and their trial community.

Predictors of Default from Treatment for Tuberculosis: a Single Center Case-Control Study in Korea.

Default from tuberculosis (TB) treatment could exacerbate the disease and result in the emergence of drug resistance. This study identified the risk factors for default from TB treatment in Korea. This single-center case–control study analyzed 46 default cases and 100 controls. Default was defined as interrupting treatment for 2 or more consecutive months. The reasons for default were mainly incorrect perception or information about TB (41.3%) and experience of adverse events due to TB drugs (41.3%). In univariate analysis, low income (< 2,000 US dollars/month, 88.1% vs. 68.4%, P = 0.015), absence of TB stigma (4.3% vs. 61.3%, P < 0.001), treatment by a non-pulmonologist (74.1% vs. 25.9%, P < 0.001), history of previous treatment (37.0% vs. 19.0%, P = 0.019), former defaulter (15.2% vs. 2.0%, P = 0.005), and combined extrapulmonary TB (54.3% vs. 34.0%, P = 0.020) were significant risk factors for default. In multivariate analysis, the absence of TB stigma (adjusted odd ratio [aOR]: 46.299, 95% confidence interval [CI]: 8.078–265.365, P < 0.001), treatment by a non-pulmonologist (aOR: 14.567, 95% CI: 3.260–65.089, P < 0.001), former defaulters (aOR: 33.226, 95% CI: 2.658–415.309, P = 0.007), and low income (aOR: 5.246, 95% CI: 1.249–22.029, P = 0.024) were independent predictors of default from TB treatment. In conclusion, patients with absence of disease stigma, treated by a non-pulmonologist, who were former defaulters, and with low income should be carefully monitored during TB treatment in Korea to avoid treatment default.

Challenges in Exploratory Methods for Tuberculosis Research in South Africa.

Haunted by a legacy of apartheid governance that left millions in material poverty, South Africa has among the highest tuberculosis (TB) morbidity and mortality rates in the world. Our Social Markers of TB research project shared a vision of working with ethnographic research methods to understand TB-infected persons, their families, care providers, and social networks. We argue that felt and enacted TB stigma and the related HIV-TB stigma impaired our ability to collect the necessary data for a full portrait of TB-infected persons and their lived conditions. To circumvent this limitation, each researcher improvised and augmented conventional anthropological methods with more creative, directed, and at times destabilizing methods. We present three case studies as useful illustrations of the complexities and challenges we encountered in our attempts to conduct ethically sound TB research. We discuss the implications of our call for "improvisation" for the politics of research and ethical oversight.

TB meets IE: contributions of ethnography

Ethnographic methods can broaden impact evaluation by adding to randomised control trials to assess the effects of international development programmes. This article uses ethnographic findings on tuberculosis (TB) in the Philippines to analyse results of quantitative research and to assess an evaluation of the United States Agency for International Development (USAID)/Philippines TB portfolio. Ladia’s ethnographic research explains critical aspects of TB patient and provider behaviour, often influenced by the stigma of TB, leading patients to adopt less effective care and ultimately sustaining the spread of the disease. Ethnography can provide information crucial to project success and to the evaluation of project effects.