S E T T ING: Urban Blantyre, Malawi.
OBJECTIVE : To understand why men with tuberculosis
(TB) in the community remain undiagnosed.
DESIGN: 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 ¼ 6) and health care
workers (n ¼ 2), and 2) in-depth interviews with TB
patients (n¼20, females n¼14) and chronic coughers (n
¼ 20, women n ¼ 8). Data were analysed inductively to
identify, refine and consolidate, and verify emerging
concepts and themes.
RE SULT S : 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 HIVas 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.
CONCLUS IONS : 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.
KEY WORDS : health care seeking; qualitative; gender