Department of Public Health and Caring Sciences Course Code: 3FV182. Transtheoretical model for Tuberculosis among foreign-born population Sweden

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1 Department of Public Health and Caring Sciences Course Code: 3FV182 Transtheoretical model for Tuberculosis among foreign-born population Sweden Author: Vitalina Pishchenko Course: Challenges in Global Health, 7.5 ECTS Autumn 2015 Examiner: Pranee Lundberg

2 Table of Contents Abstract... 3 Background... 3 Problem description and research question... 3 Theoretical background... 4 Materials and methods... 5 Results... 7 Pre-contemplation stage... 7 Contemplation... 8 Action stage... 9 Maintenance stage Discussion Limitations Recommendations Conclusion References Appendix 1. Statistics

3 Abstract The study approaches foreign-born population with a high risk of TB development. It tires to answer a question on how to induce a behavioral change in the designated population and increase prevention and screening in Sweden. The study is based on the Transtheoretical Model of Behaviour Change (TTM) which helps to determine difference stages that an individual need to pass in order to achieve a new healthy behavior. The method used in this paper is literature review where ten different articles reviewed all the stages of the applied model in their respective domain. In the conclusion one can find that the model was beneficial to see where exactly there are drawbacks for a foreign-born individual to embrace a new behavior, which are cultural barriers, language barriers, lack of information about the disease, treatment vs prevention practices, status of a foreign born individual in the host country and pre immigration experience. Background Tuberculosis (TB) has been affecting the mankind for about 4,000 years. The bacillus Mycobacterium tuberculosis triggers the chronic disease (latent or active disease states). TB has a very big capacity to spread through air. As a result, it predominantly affects people s lungs and many other parts of the body (brain, kidney and possibly spine). Symptoms vary depending on the location of the bacteria inside of the body. If the person carry TB was not treated then this person on average infects 10 to 15 people annually. (Zaman, 2010) In many developed countries TB is on decline but it is not the case in many developing countries. Consequently, as the world is embracing significant migration crisis even developing countries might experience a substantial burden of the disease brought form outside. (Zaman, 2010) Problem description and research question According to Folkhalsomyndigheten (2015), the last big epidemic of TB in Sweden was in 1950s and since then we can see another trend connected to immigration. There are 392 cases of tuberculosis (TB) in 2015 with significantly high amount of relapses in Sweden, which is an increase of 6% compared to The mean age of native TB is around 50 years old and new foreign TB cases stays around 35 years old 3

4 which comprises highly active and working population that comes to Sweden. (Eurostat, 2014; Folkhalsomyndigheten.se, 2015). As it is shown on the Pic 1 in Appendix section, among all the cases, 43 cases (11%) were born in Sweden and 349 (89%) were foreign born. Folkhalsomyndigheten (2015) states that in 2014, 684 cases were reported hence the forecast for 2015 shows that there will be more than 750 new cases registered and in particular 11 cases (3%) with multiresistant stains. In regards to gender, Folkhalsomyndigheten (2015) shows that more men than women were disgnosed. In Sweden, most cases of TB appear from high-risk countries (Africa, Asia, South America and Eastern Europe). One more fact is that Folkhalsomyndigheten (2015) concludes that the infection likey happened before the arrival in Sweden (refugee camp). A guideline from the swedish healthcare authority says that it is highly recommended to consider vaccination, a chest X-ray examination, a bronchoscopy and tuberculin test. (1177.se, 2015) According to Wolff et al (2009), there are always hurdles in executing a significantly large scale screening for TB in a whole population of migrants. It is connected to motivation factors to participate and solicitate. Many migrants or foreign born nationals live clandestinely or change their residence as well as systematic screening available from local authorities might be considered as fearful due to an idea of deportation. Another significant aspect is a cultural barrier that might also compromise voluntarily screening procedures. As a result, the aim of the study is to investigate what triggers the behavioral change in the foreign born population that is at high risk of TB. The question of the study is how to induce a behavioral change in the foreign-born population for tuberculosis prevention and screening based on the Transtheoretical Model of Behaviour Change (TTM). Theoretical background The TTM model or Stages-of-Change-Theory is beneficial in the study of TB as it tackles foreign-born population and their uncertainty and risk levels when arriving to a new country. The model can help to see how to elaborate on every stage and find some solid support to overcome the obstacles and improves people s healthy lives as achieving the right behavior and causing action is one of driving forces of change for a better public 4

5 health within a country. The TTM comprises of six different stages: pre-contemplation, contemplation, action, maintenance (Kelaher et al., 1999; Kirch, 2008). In the pre-contemplation stage, people do not tend to be ready and do not intend to take advantage of a new healthy behavior in at least near future that comprises of half a year time period. Possibly people might not find a need to change. This stage is considered as a learning stage, which encompasses learning about pros of changing behavior and express some emotions of the negative behavior (doing nothing). (Kelaher et al., 1999) The contemplation stage includes intention to start a new healthy behavior where pros are evident. Usually this stage encompasses other people that influence the adoption of the behavior. (Kelaher et al., 1999; Kirch, 2008) The preparation stage is renown for its action and small steps towards making the new behavior to take place in real everyday life. In this stage, a person adopting a new behavior becomes an advocate and encourages its friends and family. The action and maintenance stages are connected to adoption of a new behavior and an idea to keep a commitment to change. These stages connected to education and reward in order to maintain a healthy behavior to continue as a part of their life. (Kelaher et al., 1999) Materials and methods In order to answer the research question literature review was performed. The articles for the study were searched via differed electronic databases in order to scan for the key words. The databases include: ncbi.nlm.nih.gov, Uppsala University library searching engine and Sciencedirect. The key words included: tuberculosis, Sweden, Europe, foreign born, migrants, immigrants, TTO, Transtheoretical model. Based on the search particular articles were chosen in order to align with the parts of the model. A table was created in order to systematically access each of the articles and to combine them into the relevant stages of the TTO model. Further through the study the words foreign born and migrants would be used interchangeably. 5

6 Article Aim Method Results Kelaher et al (1999) Application of the TTO to cervical cancer screening in Queensland to enhance participation Focus groups and structured interviews Pre-contemplation and Contemplation stages are the most advantageous and also hard to achieve in the Stewart et al (2003) Dhuria et al (2008) Klinkenberg et al (2009) Kulane et al (2010) Wieland et al (2010) Examination of preventive measures for tuberculosis Examination of quality of life in TB Assessment of the effectiveness of tuberculosis (TB) screening methods and strategies in migrants in the EU Assessment of tuberculosis as a critical public health concern in Sweden Perceptions of tuberculosis among immigrants and refugees Literature review Systematic literature review Systematic literature review Focus group Focus groups beginning Present therapies and vaccination among high risk population Summary of significant uncertainties surrounding health status measurements Screening, community and illegal migrant shortcomings discussed In depth formulations from foreign born people of ideas on tuberculosis and problems of reporting it, assessment of knowledge regarding TB Multiple challenges with TB prevention and control identified Deribew et al (2010) Assessment of Prejudice and misconceptions about tuberculosis and HIV Questionnaire by health professionals Education and social barriers Pareek et al (2012) Abarca Tomas et al (2013) Mangan et al (2013) Assessment of the prevalence of latent infection in immigrants to the UK to define which groups should be screened and to quantify costeffectiveness Assessment of perceptions, knowledge, attitudes and treatment adherence behavior relating to TB and their social implications Examination of the development of testing messages to encourage tuberculosis testing Analysis of the medical data from UK medical centers Systematic review Interviews Latent infection, knowledge and what can be done discussed Understanding immigrants' views of TB and the obstacles Active and passive state, assessment of seeking for help, discussions about TB with participants, reaction on different messages from participants 6

7 Results The method used in this paper is literature review in order to find support and evidence to the applied model. All the stages are examined and discussed based on the application of the relevant articles found during the data collection. Pre-contemplation stage This chapter starts with a discussion of the pre-contemplation stage of the current TB situation where an individual is unconvinced of the need of change. According to the study done inside Sweden by Kulane et al (2010), many foreign-born individuals tend to avoid participation in the health care services due to a variety of factors like socio-economic, cultural, environmental and political factors which tend to develop in parallel to each other. Subsequently, foreign-born individuals tend to exercise some skepticism towards TB and in many cases neglect revealing their symptoms to a doctor instead participants of the study believe that it is better for a doctor to find it on its own based on medical examination. Kulane et al (2010) provides a very distinct feature to Sweden that might be diminishing for exercising a need to be checked for TB. This feature is that a person diagnosed with TB needs to provide the details of all the people who were in contact with the infected person. The study provides a quote from its focus-group discussion to support the idea: We [foreign-born people] are coming from a country where one looks for government authorities but have never seen government authorities looking for us. According to Kulane et al (2010), another finding specific to Sweden is that there is a great use of interpreters. In other words the use of non-professional interpreter such as a relative or a friend is not regarded as acceptable. Consequently, it causes some degree of negativity towards willingness to develop a new behavior to test for TB, as TB is a sensitive issue. The last significant aspect that Kulane et al (2010) examined was the knowledge about the latent form of TB. As a result, none of the focus group participants mention the latent form of TB and led to the conclusion that there was a lack of knowledge when it comes to TB. Another article by Dhuria et al (2008) devoted a lot of its research to the environmental factors that can be a barrier to change the behavior towards TB. These environmental factors are: safety, security, home environment, transport, and financial stability if one is discovered with TB. 7

8 More supporting evidence was found in the study done outside Sweden by Wieland et al (2010), which found that many foreign-born people tend to have heard about TB and exercise a certain degree of fear. Another study by Deribew et al (2010) adds that many of foreign-born people lack awareness of symptoms that leads to a great delay in seeking help. Another finding is that some individuals tend to try their own home country methods of treatment like ventilation or dumping of sputum. Deribew et al (2010) found that there was a high level of public prejudice. Moreover many foreign-born individuals came from home countries with a significant amount of dissatisfaction with local services. Wieland et al (2010) studied some circulating ideas that affected the decision to seek medical advice in a host country. These ideas are ideas of dying from a harsh disease, infecting other people and social isolation. Moreover, many participants in the study expressed a strong adverse need to talk about TB and try to keep it secret. The privacy or secrecy is considered as a mean to escape isolation that may come with diagnosis since it might take at least half a year of isolation during the whole process of treatment. Wieland et al (2010) states that in some countries with high TB prevalence the tag of TB is connected to shame. Another aspect is that many participants in the study expressed that if they were not sick meant that they could avoid testing for being unreasonable. As a result, it shows the lack of knowledge about the disease and a possibility to be infected (latent TB). Wieland et al (2010) concludes that there was difficulties in transportation to testing facilities as well as it could take extensive time from employed part of the population as testing centers normally working during work hours. Pre-contemplation stage can be well associated with the experience that a foreign born person when arrive to a new country (Wieland et al, 2010) Contemplation The next article will discuss the contemplation stage where a person starts to weight all the pros and cons of a possible change. Many people at this stage try to perform research and find what exactly needed for the change to occur. (Kelaher et al., 1999) The contemplation stage is a very important part due to the idea that an individual searches for the information and that information should be available for an individual to make it happen. (Abarca Tomas et al, 2013) 8

9 According to Abarca Tomas et al (2013), the information gathering for the change in the behavior can be instigated by the information from the government that in order to keep the legal status one needs to do complementary screening as well as extra information that negative result brings to escape from stigma connected to TB infection. During contemplation stage, Abarca Tomas et al (2013) shows some important shortcomings like illiteracy among foreign-born nationals and local language prevalence, neglect of symptoms and self-medication. Action stage Pareek et al (2012) observed in their study of industrialized countries that epidemiology is continuing mostly due to reactivation of latent TB. The study found that on a country level there is an active politic towards screening for active TB but in order to approach the latent form of TB it requires each individual to be aware of the risks that it can involve. Pareek et al (2012) and Aldridge et al (2014) describe what an individual might do in order to adopt a new behavior to proceed with the screening and early detection. Both of the studies had a categorization between the foreign born individuals. They classified migrants as migrant, asylum seeker, foreign-born citizen and undocumented or illegal migrant. They emphasis that the approach used in all of the categories vary. It identified some of the appearing problems like pre-migration experience with screening might be costly and discouraging for all the foreign born categories. It all reflects upon why not so many individual reach the action stage of the TTO model. Another studies by Klinkenberg et al (2009) and Pareek et al (2011) attempt to discuss in depth what modifications individuals can do to change their current state and pursue more healthy seeking behavior. Most foreign-born individuals in the studies especially illegal immigrants find it hard to be included in the screening programs although they might be actively seeking to reduce the burden of the disease. All European countries are elaborating on the follow-up system, which can help to get more from the entry screening procedures. More and more foreign-born individuals find TB to be included in their overall healthcare. Both articles provide a great amount of uncertainty when it comes to what kind of screening is beneficial for an individual. In one instance it can be a disease screening but in another instance it can be a preventive treatment in order to completely eliminate the TB infection. The individual might experience difficulty when it comes to what exactly one needs to be acting upon whether it is prevention or a disease treatment. The studies observe that testing people by the means of tuberculin skin test and hindering 9

10 the behavior to seek the test might be an easy and efficient way of preventing TB cases among foreign born population. Maintenance stage The maintenance stage is associated with a successful maintaining a new acquired behavior. This stage is connected to people that already aware about a new beneficial behavior and tend to reward them about the progression that they achieved over time. (Kirch, 2008) According to Stewart et al (2003), on a global scale people that tend to be fully aware of the consequences for them and their communities can continue to seek more advice and tend to agree to preventive therapy where they understand that the effectiveness correlates with prolonged drug intake. Moreover, Stewart et al (2003) states that it can be highly beneficial to understand and justify risks of post-exposure vaccination in order to boost the immune system. According to Stewart et al (2003) and Mangan et al (2013), people at risk coming from a high TB prevalence country can benefit from enhanced tools for the diagnosis. Some of the tools that can be available encompass new immunologic tests, new drugs and new vaccines. Furthermore, Mangan et al (2013) discusses the idea of dispelling myths and misconceptions about TB and its treatment that would not undermine foreign-born people self-esteem and stigmatize them. Stewart et al (2003) concludes that every person can contribute to make a valuable global impact. The stage can be enhanced with an idea from the study that powerful interventions on the countrywide level will find more response when it comes to the prevention of the latent forms of TB. Discussion The pre-contemplation stage shows that there are many obstacles that foreign-born people face upon arrival to Sweden. These obstacles vary it their intensity and their nature. Some of the obstacles have social-economic character and others are connected to financial stability or political status. Although the authorities try to make the procedure easier and more comfortable for the newcomers it is still problematic as per the case with interpretation problems by Abarca Tomas et al (2013). In the pre-contemplation stage one can see that it is very hard to get the right impulse from foreign-born people to feel the need and to get the sense of importance for 10

11 preventive or treatment measures when it comes to TB. The TB is still considered as a sensitive matter and possesses a high degree of stigma among the foreign born people in Sweden. During the contemplation phase is connected to the active information search. The source of the information can be anything from the Internet to the family. Although on the stage we can also meet some resistance due to the language and information availability constraints. During the action stage there is more confidence and many migrants possess a certain level of information, which together with the implemented local policies contributes to seeking help within the host country medical service facilities. This stage shows that many had at least once contact with Swedish health providers through the screening processes and tend to spread their knowledge to others. One drawback for the action stage and previous stages is connected to unfamiliarity with local health facilities which makes it hard to navigate for a foreign born individual. During the action stage one can discuss many educational programs, which become more familiar to a foreign born population. During the maintenance stage the behavior is already set in the mind of foreign born individuals and many seek new methods and cures for the TB. The last stage of the model says that an individual that reaches this state then the behavior is recognized as favorable and in many cases kept throughout the time. Based on the articles we can see that when foreign-born individuals familiarize themselves with a host country during a long period of time and move from migration phase to become fully integrated into the community they apply the overt type of behavior and use medical facilities freely as well as favor the vaccination of them and their family members. As a result, the answer to the research question is contented in over-coming the precontemplation and contemplation stages which is in line with the research by Kelaher et al (1999), which applied the TTO model to study cervical cancer screening. Limitations The study had a very short time frame this is why it was problematic to cover more articles and do an extensive systematic literature review as well as to d the longitudinal research. The choice of the article can have predominantly focused on learners experiences in the study course settings and might have to some extent based on the subjective choice. 11

12 The articles cover not only Sweden but also cover other parts of the world that can lead to certain differences in the healthcare and respective outcomes of the study. The placement of the articles onto different stages can have some degree of author s subjective view. The TTO model is a very complex model and it can be hard to grasp the whole complexity and applied it to a particular disease. Recommendations Policy makers and health professionals need to pay attention on the relevancy of the TB and its future implications due to the migration problems. Both authorities are recommended to focus on overcoming foreign-born population pre-contemplation believes that encompass social-economical, political and financial factors. The most resources need to be focused around pre-contemplation and contemplation stages, which become cost-effective in the future during the action and maintenance stages. Conclusion The TB disease is a multifaceted disease caused by bacterial populations, which can be hard to eradicate completely. People at risk can benefit from adopting a new behavior in a country where the disease tends to be lower and under the control. The model in the study approached to reflect on the idea that every foreign-born migrant goes through different stages of adoption of a new behavior applied upon the arrival to the new host country from the pre-contemplation stage when the individual is doubting the relevancy of the screening to the idea of maintaining new adopted behaviors in order to be beneficial on the individual and community level. The stages usually have their own limitations and this paper can be very informative for healthcare professionals and policy makers in order to help each individual to embrace healthcare system and make adjustments for a better overall outcome of the public health. 12

13 References 1177.se, (2015). Tuberkulos tbc Vårdguiden - sjukdomar, undersökningar, hitta vård, e-tjänster. [online] Available at: [Accessed 22 Oct. 2015]. Abarca Tomás, B., Pell, C., Bueno Cavanillas, A., Guillén Solvas, J., Pool, R. and Roura, M. (2013). Tuberculosis in Migrant Populations. A Systematic Review of the Qualitative Literature. PLoS ONE, [online] 8(12), p.e Available at: [Accessed 24 Oct. 2015]. Aldridge, R., Yates, T., Zenner, D., White, P., Abubakar, I. and Hayward, A. (2014). Preentry screening programmes for tuberculosis in migrants to low-incidence countries: a systematic review and meta-analysis. The Lancet Infectious Diseases, [online] 14(12), pp Available at: Deribew, A., Abebe, G., Apers, L., Jira, C., Tesfaye, M., Shifa, J., Abdisa, A., Woldemichael, K., Deribie, F., Bezabih, M., Aseffa, A. and Colebunders, R. (2010). Prejudice and misconceptions about tuberculosis and HIV in rural and urban communities in Ethiopia: a challenge for the TB/HIV control program. BMC Public Health, [online] 10(1), p.400. Available at: [Accessed 25 Oct. 2015]. Dhuria, M., Sharma, N. and Ingle, G. (2008). Impact of tuberculosis on the quality of life. Indian J Community Med, [online] 33(1), p.58. Available at: [Accessed 25 Oct. 2015]. EUROSTAT, (2014). Tuberculosis surveillance and monitoring in Europe Surveliance Report. [online] ECDC Europe. Available at: den-tuberculosis-country-profile-2014.pdf [Accessed 16 Oct. 2015]. Folkhalsomyndigheten, (2015). Antal TB-fall i Sverige jan-jun 2015 per åldersgrupp och födelseland (n=392). [image] Available at: [Accessed 22 Oct. 2015]. Folkhalsomyndigheten.se, (2015). Tuberkulos Folkhälsomyndigheten. [online] Available at: [Accessed 22 Oct. 2015]. Kelaher, M., G. Gillespie, A., Allotey, P., Manderson, L., Potts, H., Sheldrake, M. and Young, M. (1999). The Transtheoretical Model and Cervical Screening: Its application among culturally diverse communities in Queensland, Australia. Ethnicity & Health, [online] 4(4), pp Available at: [Accessed 16 Oct. 2015]. Kirch, W. (2008). Encyclopedia of public health. New York: Springer. 13

14 Klinkenberg, E., Manissero, D., Semenza, J. and Verver, S. (2009). Migrant tuberculosis screening in the EU/EEA: yield, coverage and limitations. European Respiratory Journal, [online] 34(5), pp Available at: [Accessed 24 Oct. 2015]. Kulane, A., Ahlberg, B. and Berggren, I. (2010). It is more than the issue of taking tablets : The interplay between migration policies and TB control in Sweden. Health Policy, [online] 97(1), pp Available at: [Accessed 25 Oct. 2015]. Mangan, J., Galindo-Gonzalez, S. and Irani, T. (2013). Development and Initial Testing of Messages to Encourage Tuberculosis Testing and Treatment Among Bacille Calmette- Guerin (BCG) Vaccinated Persons. Journal of Immigrant and Minority Health, [online] 17(1), pp Available at: [Accessed 25 Oct. 2015]. Pareek, M., Baussano, I., Abubakar, I., Dye, C. and Lalvani, A. (2012). Evaluation of Immigrant Tuberculosis Screening in Industrialized Countries. Emerg. Infect. Dis., [online] 18(9), pp Available at: [Accessed 24 Oct. 2015]. Pareek, M., Watson, J., Ormerod, L., Kon, O., Woltmann, G., White, P., Abubakar, I. and Lalvani, A. (2011). Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis. The Lancet Infectious Diseases, [online] 11(6), pp Available at: [Accessed 24 Oct. 2015]. Stewart, G., Robertson, B. and Young, D. (2003). Tuberculosis: a problem with persistence. Nature Reviews Microbiology, [online] 1(2), pp Available at: [Accessed 25 Oct. 2015]. Wieland, M., Weis, J., Yawn, B., Sullivan, S., Millington, K., Smith, C., Bertram, S., Nigon, J. and Sia, I. (2010). Perceptions of Tuberculosis Among Immigrants and Refugees at an Adult Education Center: A Community-Based Participatory Research Approach. Journal of Immigrant and Minority Health, [online] 14(1), pp Available at: [Accessed 24 Oct. 2015]. Wolff, H., Janssens, J., Bodenmann, P., Meynard, A., Delhumeau, C., Rochat, T., Sudre, P., Costanza, M., Gaspoz, J. and Morabia, A. (2009). Undocumented Migrants in Switzerland: Geographical Origin Versus Legal Status as Risk Factor for Tuberculosis. Journal of Immigrant and Minority Health, [online] 12(1), pp Available at: [Accessed 24 Oct. 2015]. Zaman, K. (2010). Tuberculosis: A Global Health Problem. J Health Popul Nutr, [online] 28(2). Available at: [Accessed 22 Oct. 2015]. 14

15 Appendix 1. Statistics Pic 1. Comparison of TB cases among Swedish-born and foreign-born individuals from January to June 2015 (Folkhalsomyndigheten, 2015) 15