{
  "abstract": "Objectives Non-adherence to tuberculosis (TB) treatment remains a major challenge in high-burden regions. However, few studies have qualitatively examined the sociocultural and emotional barriers to adherence, particularly among Afghan refugees in Pakistan. This study explores the patient-related, sociocultural and treatment-related barriers to treatment adherence among patients with TB of Pakistani and Afghan origin living in Pakistan.Design We conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) and in-depth interviews (IDIs) with purposively selected multisectoral stakeholders. The data were analysed thematically using a combination of inductive and deductive approaches.Settings We employed a qualitative study design in the TB DOTS (Directly Observed Treatment Short course) centres in the Haripur and Peshawar districts of Khyber Pakhtunkhwa province, Pakistan.Participants We conducted IDIs (n=29) and FGDs (n=11) with three categories of participants: TB healthcare providers, patients with TB and their carers.Results We identified several contributors to lower treatment adherence. These included patient-related barriers (eg, lack of awareness about TB and its treatment), sociocultural barriers (eg, stigma, refugee status of Afghan patients, gender roles and reliance on traditional and spiritual healing) and treatment-related barriers (eg, demanding treatment regimen and TB-induced depression).Conclusion Several personal, sociocultural and treatment-related barriers contribute to lower treatment adherence in patients with TB. A significant contributing factor to treatment non-adherence in patients is the high prevalence of anxiety and depression related to TB and its treatment, for which there is no treatment or counselling available at the DOTS level in Pakistan, warranting the need for mental health interventions that could improve adherence and treatment outcomes for both TB and depression.Trial registration number ISRCTN10761003.",
  "authors": [
    {
      "affiliations": [
        "Department of Sociology, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Noor Sanauddin"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Fayaz Ahmad"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Maryiam Rahim"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Muhammad Awais Paracha"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Zohaib Khan"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Fatima Khalid Qazi"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Shaista Rasool"
    },
    {
      "affiliations": [
        "Mayo Hospital, Lahore, Punjab, Pakistan"
      ],
      "name": "Mirrat Butt"
    },
    {
      "affiliations": [
        "Psychiatry, Queens University of Charlotte, Charlotte, North Carolina, USA"
      ],
      "name": "Farooq Naeem"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Muhammad Firaz Khan"
    },
    {
      "affiliations": [
        "School of Medicine, Keele University, Keele, Staffordshire, UK"
      ],
      "name": "Saima Sheikh"
    },
    {
      "affiliations": [
        "Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Zeeshan Kibria"
    },
    {
      "affiliations": [
        "School of Medicine, Keele University, Keele, Staffordshire, UK"
      ],
      "name": "Nishani Fonseka"
    },
    {
      "affiliations": [
        "Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan"
      ],
      "name": "Mian Ul-Haq"
    },
    {
      "affiliations": [
        "School of Medicine, Keele University, Keele, Staffordshire, UK"
      ],
      "name": "Saeed Farooq"
    }
  ],
  "title": "Barriers to treatment adherence among patients with tuberculosis: a qualitative study of Pakistani nationals and Afghan refugees",
  "uid": "5d6fdd36-998e-588b-b83b-7c26c28ed5cb"
}