Assessment of Quality of Life, Adherence, and Stigmatization among People Receiving Anti-Tuberculosis Medications in Three Tertiary Hospitals in Sierra Leone: A Cross- Sectional Study

Assessment of Quality of Life, Adherence, and Stigmatization among People Receiving Anti-Tuberculosis Medications in Three Tertiary Hospitals in Sierra Leone: A Cross- Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Quality of Life, Adherence, and Stigmatization among People Receiving Anti-Tuberculosis Medications in Three Tertiary Hospitals in Sierra Leone: A Cross- Sectional Study Michael Lahai, Sally-Mattu Conteh, Ahmed Vandy, Onome T Abiri, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6187729/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Jul, 2025 Read the published version in Discover Public Health → Version 1 posted 15 You are reading this latest preprint version Abstract Background Tuberculosis (TB) remains a significant public health concern, particularly in resource-limited settings, where the burden of TB is compounded by socioeconomic challenges and stigmatization. This study assessed the quality of life, treatment adherence, and stigmatization among patients receiving anti-TB medications in three tertiary hospitals in Sierra Leone. Method A cross-sectional study of 384 patients at Connaught, Lakka, and Kenema government hospitals was conducted between May to July 2021. Data was collected using a structured pre-tested questionnaire, consisting of the Morisky adherence scale, WHO Quality of Life tool, and Stigma Scale for Chronic Illnesses to measure adherence, quality of life and stigma respectively. Data was analyzed using descriptive and inferential statistics using the Statistical Package for Social Sciences 16. Associations between independent variables and quality of life were determined using an independent sample T-test and ANOVA. Post hoc analysis was further conducted for variables that were significant using backward multivariate linear regression. Results More than half of the patients were male with a mean age of 33.92 years. The overall adherence rate among the patients in our study was 96.9%. The social relationship domain (64.65, SD = 15.6) recorded the highest Quality of Life score, while the environmental health domain (58.18, SD = 13.5) was the lowest. The result of the backward multivariate linear regression revealed patient age to be statistically significant with the physical Health (P-value = 0.000), psychological Health (P-value = 0.017) and environmental health domains (P-value = 0.005). Having kids, Marital status, religion, and family economic situation were also found to be statistically significant with various other individual quality of life domains. The stigma indicators in this study were low with 24 (6.3%) and 50 (13.0%) of the patients reporting rejection from spouse and other family members respectively. Conclusion Despite the study revealed an encouraging adherence rate, gaps in the psychological and environmental quality of life, along with stigma, require urgent public health action. Enhancing family support, reducing economic burdens, and combating stigma through public sensitization is crucial for better outcomes for TB patients. Quality of life adherence stigmatization Antituberculosis medicines Sierra Leone Introduction Tuberculosis continues to pose a significant global public health challenge despite extensive efforts to control and treat the disease using cost-effective drugs and interventions ( 1 , 2 ). Each year, TB affects approximately 10 million individuals, with 1.5 million succumbing to the disease despite its preventable and treatable nature, making it one of the leading infectious causes of death globally ( 3 , 4 ). According to the World Health Organization (WHO), approximately 480,000 people had multidrug-resistant TB (MDR-TB) in 2014, resulting in 190,000 deaths from this form of the disease ( 5 ). Although the global TB incidence rate is declining, it is not on track to meet the 2020 target of a 20% decrease from 2015 to 2020. The total decrease from 2015 to 2019 was 9% (from 142 to 130 new cases per 100,000 people), with a 2.3% fall from 2018 to 2019 ( 4 ). One of the key obstacles to effective medical treatment is the patient's failure to adhere to the instructions and recommendations from their healthcare providers ( 6 ). Adherence is essential in treating tuberculosis to achieve the required treatment success rate ( 7 ). However, due to the long treatment duration (intense phase of two months and continuation phase of six to nine months) for newly diagnosed patients and (12 months or at most two years) for multi-drug resistance (MDR) patients, adherence to TB treatment is the most challenging factor affecting TB control ( 8 , 9 ). Non-adherence can lead to poor treatment outcomes, relapse and development of multi-drug resistance Tuberculosis MDR-TB ( 7 ). According to WHO, Patients' adherence to their medication regimens has been reported to be influenced by the interaction of several factors which can be grouped as social and economic factors, health-care team and system-related factors, condition-related factors, therapy-related factors, and patient-related factors ( 10 ). These factors that influence patient adherence to TB treatment vary in different populations. Those that emerged in our current study might be similar to, or different from, those reported in other areas in Sierra Leone. Currently, TB control programs focus on achieving microbiological cure as the main measure of successful treatment ( 11 ). However, this approach does not fully consider the physical, mental, and social impact of TB on patients. Patients may not only suffer from the symptoms of the disease but also experience a decline in their overall quality of life (QoL), which is believed to have a major influence on adherence and overall clinical outcomes ( 12 , 13 ). Understanding the disease burden based on all predicted QoL domains is crucial, especially in low-income countries ( 14 ). The stigma associated with TB also presents a major obstacle to TB control as it causes delays in diagnosis and non-compliance with treatment ( 15 ). The stigmatizing attitudes and behaviours of community members in low-income countries towards the disease may lead affected individuals to live in isolation, hide the diagnosis from others and default treatment ( 16 ). TB-related stigma and discrimination can lead to social exclusion, marginalization, and participatory restrictions on those suffering from the disease ( 17 – 19 ). To date, health professionals and TB program staff in Sierra Leone have limited evidence on TB treatment adherence and barriers or enabling factors to treatment optimization. Our current study has determined the adherence to TB medication, the quality of life of TB patients, the association of socio-demographic factors to the quality of life, and the effect of stigmatization on people receiving anti-TB medications at three tertiary hospitals in Sierra Leone (Lakka hospital, Connaught hospital, and Kenema government hospital). The findings from this research will provide valuable insight into the challenges faced by TB patients in Sierra Leone and inform strategies to improve treatment outcomes and reduce the stigma associated with the disease. Methods Study Design, setting and duration This was a cross-sectional facility-based study conducted between May to July 2021 at three tertiary hospitals in Sierra Leone: Kenema Government Hospital in the Eastern region, Lakka Hospital in the Western Area Rural, and Connaught Hospital in the Western Area Urban of Freetown. These hospitals are the main referral centres for TB care in two of the four regions of the country. Study population and sample size The study population consisted of all patients aged 18 years and above who had been on anti-TB medication for more than four months and were attending the TB clinics at the selected hospitals. The sample size of 384 was calculated using Fisher's formula, n = z 2 pq/d 2 , where n = sample size, p = 0.05, assuming 50% of the overall population, z score of 1.96 that corresponds to a 95% confidence interval and an accepted error of 5%. Eligibility criteria All TB patients aged 18 years and above who were actively on Antitubercular medications at these facilities for over four months of treatment were included in this study. Consent for participation was requested from all participants, and all participants were informed of their right to participate or refuse participation in the study at any time during the interview. Six patients at Lakka Hospital and four patients at Connaught Hospital were excluded from the study because they did not consent to participate in the study. Criteria for exclusion included; TB patients seeking temporal treatment from the facility and patients that are too sick or mentally incompetent to be interviewed. Outcome measures and data collection An interviewer-administered questionnaire was used for data collection. The questionnaire had four sections: patients' Socio-demographic, patients' adherence Scale, TB-related Stigma questions, and quality of life questions. The dependent variables in this study were the four quality of life domains (Physical Health, Psychological Health, Environmental Health, and Social Health), which were measured using the WHO Quality of Life-BREF (WHOQOL-BREF) tool. Adherence was measured using the 8-Item Morisky adherence self-reporting tool. The first seven questions on the scale required a ‘Yes’ or ‘No’ response, while the last question utilized a five-point Likert scale “always,” “usually,” “sometimes,” “once in a while,” and “never”. We also adapted the 8-item Stigma Scale for Chronic Illnesses (SSCI) to assess stigmatization ( 20 ). Data collectors were trained on the data collection procedure using an interviewer-administered format. Statistical analysis Reliability and validity of the instrument were checked by determining Cronbach's alpha value, for which an alpha value greater than or equal to 0.70 was deemed acceptable, while Pearson’s correlations above 0.4 were considered to be acceptable. Descriptive statistics were used to analyze categorical and continuous variables. The 8-item adherence assessment was scored as done in a similar study ( 21 ); the first seven questions were scored as 1 for each “Yes” response and 0 for “No” response. The last question which had the Likert scale was scored as 1 for "never”, 0.75 for 'once in a while' and 'sometimes', while 'usually' was scored as 0.25 and 'all the time' was scored as 0. An aggregate score of the 8-item questions of 0 to less than 4 was categorized as adherent and 4 to 8 as non-adherent. Bivariate associations between independent variables and quality of life (transformed scores of four domains) were determined using an independent sample T-test and Analysis of Variance (ANOVA). Post hoc analysis was further conducted for domains that showed significant differences using backward multivariate linear regression, with a P-value less than 0.05 considered statistically significant. Results Socio-demographic and other related characteristics Table 1 provides detailed information about the sociodemographic distribution of the patients from the three hospitals, 160 (41.7%) were from Connaught Hospital, 152 (39.6%) from Lakka Hospital, and 72 (18.7%) came from Kenema Government Hospital. The mean age of the participants was 33.92 years. More than half of the patients were male living with an extended family. About 46.4% were married and 32.3% had no formal education. The overall treatment adherence level was 96.9%. Table 1 Socio-demographic and other characteristics Variables Frequency (%) Facilities Connaught Hospital Lakka Hospital Kenema Government Hospital 160(41.7%) 152 (39.6%) 72 (18.7%) Age < 40years ≥ 40years 280 (72.9) 104 (27.1) Gender Male Female 226 (58.9) 158 (41.1) Religion Christianity Islam 162 (42.2) 222 (57.8) Marital status Single Married Divorced Widow/Widower 167 (43.5) 178 (46.4) 15 (3.9) 24 (6.3) Do you have kids Yes No 272 (70.8) 112 (29.2) Type of family Nuclear Single parent Extended 112 (29.2) 79 (20.6) 193 (50.3) Educational level No formal education Elementary High school College (diploma above) 124 (32.3) 75 (19.5) 116 (30.2) 69 (18.0) Living arrangement Rent Own Staying at a friend’s place 225 (58.6) 151 (39.3) 8 (2.1) Family economic situation Good Moderate Poor 57 (14.8) 226 (58.9) 101 (26.3) Adherence level Adherent Non-adherent 372 (96.9) 12 (3.1) Assessment of quality of life among TB patients Table 2 shows the average transformed scores of the four different domains with the social domain [64.65(SD 15.6)] and the environmental relationship domain [58.18(SD 13.5)] being the highest and lowest mean scores respectively. Table 2 Transformed Quality of Life (QOL) Domain Scores (N=384) QOL Domains Minimum Maximum Mean (SD) Physical Health 4 100 62.43 (16.4) Psychological domain 13 100 59.47 (16.3) Social relationship 8 100 64.65 (15.6) Environment 22 94 58.18 (13.5) Association between the sociodemographic variables and Quality of life domains Table 3 shows the statistically significant difference between the patient’s age and physical health (p = 0. 000), psychological health (p = 0.001) and Environmental health (p= 0.002) domains. There was also a statistically significant difference between the patient’s Religion and Environmental health domain (p= 0.000). Also, a significant difference was observed between the patient’s marital status, having kids and Family Economic Situation with all the four quality-of-life domains. In addition, there was a statistically significant difference between the type of family of the patient and the psychological health (p= 0.010) and environmental health (0.004) domains. Multivariate backward linear regression model after adjusting for other covariates revealed a significant association between the patient’s age and physical, psychological and environmental health domains. A statistically significant association was seen between patients’ family economic situation and the environmental health domains. There was also a significant association between the psychological health domain and those who had kids. A significant association was also seen between the social health domain and the patient’s marital status. This study also revealed a significant association between the environmental health domain and Patient’s religion (Table 4). Table 3. Bivariate associations between independent variables and quality of life – Independent Sample T-test and ANOVA. Characteristics Quality of life Scores Dom 1 Mean (SD) Dom 2 Mean (SD) Dom 3 Mean (SD) Dom4 Mean (SD) Patient’s Age <40 years ≥ 40 years p-value 64.5 (15.4) 56.8 (17.6) 0.000*** 61.2 (16.4) 54.8 (15.4) 0.001*** 65.0 (15.6) 63.7 (15.5) 0.468 59.5 (13.7) 54.7 (12.4) 0.002*** Patient’s Gender Male Female p-value 62.4 (17.1) 62.5 (15.4) 0.941 59.6 (17.0) 59.3 (15.4) 0.849 64.9 (16.7) 64.3 (13.9) 0.709 58.4 (13.3) 57.8 (13.9) 0.675 Patient’s Religion Christianity Islam p-value 62.4 (15.9) 62.4 (16.8) 0.993 60.6 (16.5) 58.7 (16.2) 0.261 64.3 (15.3) 64.9 (15.7) 0.709 61.3 (13.3) 55.9 (13.2) 0.000*** Patient’s Marital status Single Married Divorced Widow/Widower P-value 66.2(15.5) 60.3(15.9) 58.3(14.8) 54.6(21.2) 0.000*** 62.6(17.3) 57.2(15.2) 59.2(15.4) 54.9(15.3) 0.008** 67.5(15.7) 62.5(15.4) 62.2(15.7) 62.1(13.0) 0.018** 60.8(12.8) 56.8(13.3) 55.4(17.2) 52.1(14.3) 0.003*** Do you have Kids Yes No P-value 61.2 (16.4) 65.4 (16.2) 0.024** 57.6 (15.5) 63.9 (17.4) 0.001*** 63.3 (15.3) 67.9 (15.9) 0.009** 57.0 (13.7) 61.0 (12.8) 0.008** Type of Family Nuclear Single parent Extended P-value 63.3(15.0) 63.2(14.7) 61.6(17.8) 0.614 58.0(18.0) 64.4(13.1) 58.3(16.2) 0.010** 63.5(16.3) 65.4(13.9) 65.0(15.8) 0.658 60.3(14.4) 60.8(13.1) 55.9(12.8) 0.004*** Living Arrangement Rent Own Staying at a friend’s place P-value 62.8(16.1) 62.0(16.7) 59.4(22.4) 0.765 58.7(16.6) 61.1(15.6) 50.5(21.0) 0.116 64.7(16.1) 64.7(14.3) 60.4(22.6) 0.740 57.3(13.6) 60.0(13.2) 54.3(15.8) 0.162 Family Economic Situation Good Moderate Poor P-value 66.5(15.0) 63.0(15.1) 58.9(19.1) 0.014** 60.0(17.0) 61.4(15.9) 55.0(16.3) 0.004*** 65.2(17.1) 67.0(15.0) 59.1(14.6) 0.000*** 66.3(12.4) 60.2(12.2) 49.0(12.1) 0.000*** Adherence Level Adherent Non-Adherent P-value 62.2 (16.4) 68.5 (15.0) 0.196 59.6 (16.3) 55.2 (16.9) 0.359 64.5 (15.7) 68.1 (11.7) 0.441 58.1 (13.4) 60.9 (16.2) 0. 473 Dom1: Physical Health; Dom2: Psychological Health; Dom3: Social Health; Dom4: environmental Health Table 4. Backward multiple linear regression analyses of factors significantly associated with quality of life of Patients with TB Characteristics Quality of life scores Dom 1 Coef/P-value (95%CI) Dom 2 Coef/P-value (95%CI) Dom 3 Coef/P-value (95%CI) Dom 4 Coef/P-value (95%CI) Patient’s Age /=40 -7.669/0.000 (-11.296, -4.042) -4.720/0.017 (-8.603, -0.838) -4.172/0.005 (-7.080,-1.264) Do you have kids Yes vs No 4.636/0.017 (0.840, 8.432) Marital Status Married vs Not married 4.242/0.008 (1.139, 7.346) Patient’s Religion Christianity vs Islam -4.750/0.000 (-7.375, -2.124) Family Economic Situation Good vs Not Good -8.087/0.000 (-11.755, -4.420) Dom1: Physical Health; Dom2: Psychological Health; Dom3: Social Health; Dom4: Environmental Health Stigma scale responses The majority of the participants (70.6%) were always unhappy about how TB affected their appearance, and 55.2% avoided others for fear that they might infect them with TB. Moreover, 48.7% were certain of their recovery. More than half of the participants were always careful about whom they told they had TB, and 23.6% were worried that some people assumed they had HIV because they had TB. The result also showed that 25.5% said some people did not support them (physically/emotionally/financially) because they have TB (Table 5). Table 5 TB Stigma Scale No Questions Disagree N (%) Uncertain N (%) Agree N (%) 1 Were you unhappy about how TB affected your appearance? 36(9.4) 77(20.0) 271(70.6) 2 Did you avoid others for fear that you will infect them with TB? 83(21.6) 89(23.2) 212(55.2) 3 Are you afraid that you will not recover from TB or that you will die? 187(48.7) 82(21.3) 115(30.0) 4 Did you worry that you were a burden to others? 169(44.0) 116(30.2) 99(25.8) 5 Are you careful about who you tell you have TB? 52(13.5) 102(26.6) 230(59.9) 6 Did you worry that some people assumed that you have HIV because you have TB? 203(52.9) 80(20.8) 101(26.3) 7 Did some people avoid/keep their distance from you, for fear of infecting them with TB 161(41.9) 109(28.4) 114(29.7) 8 Did some people not support you (physically/emotionally/financially) because you have TB? 156(40.6) 130(33.9) 98(25.5) Yes (%) No (%) 8a Spouse/Boyfriend/Girlfriend, He /She rejected me 50 (13.0) 334 (87.0) 8b Other family member(s), some rejected me 24 (6.3) 360 (93.7) Discussion Our study provides valuable information for TB patients receiving antituberculosis medications with an emphasis on 3 key areas of emphasis that include Adherence to TB medication, Quality of life assessment and the association of demographic factors to quality of life and the Stigmatization of TB patients on anti-TB medication. Most of the patients in this study were adherent to their TB treatment regimen, which aligns with the findings from the University of Ilorin Teaching Hospital, Ilorin, Nigeria and Alamata District, northeast Ethiopia where 94.6% and 88.5% of the patients undergoing TB treatment were adherent ( 22 , 23 ). This high adherence rate, while encouraging, contrasts with some studies reporting lower adherence rates in other settings, such as Iran (27.54%) ( 24 ) and Ghana (76.8%) ( 25 ). This could potentially be attributed to effective Directly Observed Therapy (DOTS) programs implemented in our study sites, although further investigation is needed to confirm this. Continuous monitoring and evaluation are needed to maintain and further improve adherence rates at these facilities. TB is curable if treatment starts quickly, monitored and is consistent throughout the 6–9 month treatment duration ( 26 ). However, high default rates, interruptions, and lack of adherence, along with insufficient disease knowledge often lead to poor outcomes, particularly in developing countries. Non-adherence in TB treatment is a major concern as it has reportedly led to TB drug resistance which prolongs the infectiousness of the disease and increases the relapse and death of patients ( 27 , 28 ). The result from our assessment of the quality of life of TB patients revealed a higher mean score in the social health domain and the physical health domain, while the lowest mean score was observed in the environmental health domain. These findings suggest that while patients may have been coping well with their physical health and social relationships, environmental factors (such as living conditions, availability of healthcare facilities, and community support) and psychological health remain areas of concern, especially in our resource-constrained settings. Similar findings were also reported in a study done in Nigeria, where the environmental domain had the lowest QoL score ( 29 ). Patients with infectious TB may require hospitalization or isolation from the community, leading to not only health issues related to the disease but also psychological distress, stigma and withdrawal from environmental interaction ( 30 ). Unlike settings with robust socioeconomic support structures, the economic strain in our resource-limited settings can significantly impact environmental domains, underscoring the need for structural interventions in Sierra Leone. The bivariate associations revealed that age, marital status, those with kids, patient's religion, type of family, and family economic situation were statistically significant factors associated with patient QoL. After adjusting for other covariates, a backward multiple linear regression model showed that patient age, marital status, having kids, religion and family economic situation were statistically significant factors associated with patient QoL. For instance, patients aged less than 40 years had better physical, psychological and environmental health than older patients aged above 40 years. Younger individuals may have better resilience and coping strategies. Older patients with TB are also more likely to have adverse outcomes than younger patients, and they may face additional challenges in coping with the effects of the disease and adhering to treatment ( 31 ). Additionally, the analysis indicated that marital status, having children, and the family's economic situation significantly impacted QoL, highlighting the importance of social support and economic stability in health outcomes. The study by Sukartini et al. supports the current study's findings on the importance of family support in the management of tuberculosis patients ( 32 ). Although religion was significantly associated with the environmental health domain in our study, this finding warrants further exploration to understand the underlying mechanisms. The assessment of stigmatization revealed concerning findings. A substantial proportion of participants expressed unhappiness about how TB affected their appearance, avoided others due to fear of transmission, and were careful about disclosing their diagnosis. As stigmatization remains a significant barrier for TB patients, understanding how individuals with TB feel and cope with the stigma associated with the disease plays a vital role in understanding their health-seeking behaviour and adherence ( 33 ). It leads to social isolation, negatively impacting mental and physical health. Hindering disclosure of infections, and undermines TB screening efforts ( 15 ). For instance, the fear of being perceived as having HIV due to TB is particularly of concern in our study, as it may deter individuals from seeking timely medical help, further perpetuating the cycle of transmission and morbidity. We also highlighted the social stigma attached to TB by considering two important indicators that explained TB stigma in Sierra Leone. These indicators included rejection from their spouse and rejection from other family members. The proportion of participants who reported social rejection in our study is low relative to those observed in previous studies done in Nepal and Bangladesh ( 34 , 35 ). Counselling and support services should be provided to families of TB patients in these settings to address concerns about transmission, promote understanding, and prevent rejection. As stigma decreases self-esteem and quality of life in patients, sensitization can play a great role in combating how the society perceives and treats TB patients. This information about TB stigmatization can provide vital insights into how TB is experienced by the persons affected by TB and also help TB programs and healthcare providers provide person-centred approaches instead of disease-centred care. There is the need for continued stigma sensitization of communities with TB patients, assigning pharmacists to TB facilities for counselling patients and identification of patients that have been lost to follow-up or have the potential to be lost to follow-up. To improve treatment uptake, rural communities should be educated about the availability of treatment for TB and its potential benefits in combating the disease. A detailed study should be instituted to help understand TB's prevalence and actual threat level in the country. We recommend the need for the TB program to team up with accredited community pharmacists in various communities to provide medications at affordable prices without having to go to the hospitals for a refill. Limitations This study has some limitations. The result of this study may not be used to generalize the whole population of TB patients in Sierra Leone because of the small sample size that was focused on clinic attendance during the period of study. The reliance on self-reported data may be subject to recall bias and social desirability bias. Conclusion While adherence rates remain encouraging among TB patients, significant gaps in psychological and environmental Quality of life domains, along with pervasive stigma, demand urgent public health interventions. As the disease presents with a multidimensional health burden, strengthening family support systems, alleviating economic hardships, and addressing stigma through education and advocacy are essential multidimensional approaches for improving outcomes among TB patients. While treating the physical burden of the disease, policy initiatives should also focus on enhancing social support, providing psychological counselling, and addressing socio-economic disparities. Abbreviations Tuberculosis (TB) multi-drug resistance (MDR) multi-drug resistance Tuberculosis MDR-TB WHO Quality of Life-BREF (WHOQOL-BREF) Stigma Scale for Chronic Illnesses (SSCI) Analysis of Variance (ANOVA) Directly Observed Therapy (DOTS) Quality of life (QoL) Declarations Human Ethics and consent to participate Ethical Approval to conduct this study was obtained from the College of Medicine and Allied Health Sciences Institutional Ethics Review Board with review number COMAHS/IRB/007-2024. A letter requesting permission for data collection was sent to the hospital care manager of the three hospitals. The purpose of the study was well explained to the participants and their right to participate voluntarily. Participants were also informed that they have the right to participate or refuse participation at any time during the interview without any consequences. Informed consent was obtained from all respondents before the commencement of the interview and only those who consented were interviewed. All the patient data were kept confidential and anonymously used for this study. Ethical requirement was met throughout the research in compliance with the Helsinki declaration. Consent for publication Not applicable Availability of data and materials All datasets and reports used are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests whatsoever. Funding This study was self-funded by the research team. Authors’ contributions All authors have read and approved the manuscript. SC and ML developed the concept and proposal of the study. ML, AV, OTA, BT and PBJ provided guidance on research methods. AV, SC, ML and OTA facilitated data collection and analysed the dataset. AV, MB and SC prepared documents and framework for ethical approval and consent for the study. SC prepared the write-up and ML, AV, AT, BT and OTA provided expert review. AV, ML, OTA, MB and PBJ finalised the manuscript. Acknowledgements The authors express their sincere thanks and appreciation to all those who participated in this research. We express our thanks to all the hospital care managers where this study was conducted, with special appreciation to the coordinators and staff of the Lakka Government Hospital. Clinical trial number Not applicable References Haileamlak A. Tuberculosis Continued as Global Challenge Though the Burden Remained High in Low-Income and High-Income Countries. Ethiop J Health Sci [Internet]. 2018 Sep 1 [cited 2023 Dec 24];28(5):517. Available from: /pmc/articles/PMC6308771/ Anuwatnonthakate A, Limsomboon P, Nateniyom S, Wattanaamornkiat W, Komsakorn S, Moolphate S, et al. Directly Observed Therapy and Improved Tuberculosis Treatment Outcomes in Thailand. PLoS One [Internet]. 2008 Aug 28 [cited 2023 Dec 24];3(8):e3089. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0003089 Alimi N, Sakhi R. Knowledge, Attitude, and Practices Toward Tuberculosis Among Health Faculty and Non-Health Faculty Students of Kabul University and Kabul University of Medical Sciences, Kabul, Afghanistan. Adv Med Educ Pract [Internet]. 2023 [cited 2023 Dec 24];14:753. Available from: /pmc/articles/PMC10353910/ World Health Organization. Progress towards global TB targets – an overview. Global Tuberculosis Report 2020 [Internet]. 2020 [cited 2023 Dec 24];Chapter 2.2, 7. Available from: http://apps.who.int/bookorders. Cheon SA, Cho HH, Kim J, Lee J, Kim HJ, Park TJ. Recent tuberculosis diagnosis toward the end TB strategy. J Microbiol Methods. 2016 Apr 1;123:51–61. Jimmy B, Jose J. Patient Medication Adherence: Measures in Daily Practice. Oman Med J [Internet]. 2011 [cited 2023 Dec 26];26(3):155. Available from: /pmc/articles/PMC3191684/ Batte C, Namusobya MS, Kirabo R, Mukisa J, Adakun S, Katamba A. Prevalence and factors associated with non-adherence to multi-drug resistant tuberculosis (MDR-TB) treatment at Mulago National Referral Hospital, Kampala, Uganda. Afr Health Sci [Internet]. 2021 Mar 1 [cited 2023 Dec 25];21(1):238. Available from: /pmc/articles/PMC8356628/ Ajema D, Shibru T, Endalew T, Gebeyehu S. Level of and associated factors for non-adherence to anti-tuberculosis treatment among tuberculosis patients in Gamo Gofa zone, southern Ethiopia: cross-sectional study. BMC Public Health [Internet]. 2020 Dec 1 [cited 2023 Dec 25];20(1):1–9. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09827-7 Bea S, Lee H, Kim JH, Jang SH, Son H, Kwon JW, et al. Adherence and Associated Factors of Treatment Regimen in Drug-Susceptible Tuberculosis Patients. Front Pharmacol [Internet]. 2021 Mar 15 [cited 2023 Dec 25];12. Available from: /pmc/articles/PMC8005597/ Fernandez-Lazaro CI, García-González JM, Adams DP, Fernandez-Lazaro D, Mielgo-Ayuso J, Caballero-Garcia A, et al. Adherence to treatment and related factors among patients with chronic conditions in primary care: A cross-sectional study. BMC Fam Pract [Internet]. 2019 Sep 14 [cited 2023 Dec 26];20(1):1–12. Available from: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-019-1019-3 Aggarwal AN. Quality of life with tuberculosis. J Clin Tuberc Other Mycobact Dis. 2019 Dec 1;17:100121. Malik M, Nasir R, Hussain A. Health Related Quality of Life among TB Patients: Question Mark on Performance of TB DOTS in Pakistan. J Trop Med. 2018;2018. Juliasih NN, Mertaniasih NM, Hadi C, Soedarsono, Sari RM, Alfian IN. Factors Affecting Tuberculosis Patients’ Quality of Life in Surabaya, Indonesia. J Multidiscip Healthc [Internet]. 2020 Nov 4 [cited 2023 Dec 26];13:1475–80. Available from: https://www.dovepress.com/factors-affecting-tuberculosis-patientsrsquo-quality-of-life-in-suraba-peer-reviewed-fulltext-article-JMDH Pokam BDT, Fokam P, Njamen TN, Guemdjom PW, Asuquo AE, Pokam BDT, et al. Assessment of Health-Related Quality of Life of Tuberculosis Patients in Fako Division, South-West Region of Cameroon. J Tuberc Res [Internet]. 2020 Jul 13 [cited 2023 Dec 26];8(3):93–110. Available from: http://www.scirp.org/journal/PaperInformation.aspx?PaperID=101462 Chen X, Du L, Wu R, Xu J, Ji H, Zhang Y, et al. Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study. BMC Public Health [Internet]. 2021 Dec 1 [cited 2023 Dec 26];21(1):1–10. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-10055-2 Tadesse S. Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia. PLoS One [Internet]. 2016 Apr 1 [cited 2023 Dec 26];11(4). Available from: /pmc/articles/PMC4824500/ Mukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Ann Glob Health [Internet]. 2018 Nov 5 [cited 2023 Dec 26];84(4):727. Available from: /pmc/articles/PMC6748300/ Ortiz-Ruiz N, Díaz-Grajales C, Zamudio-Espinosa D, Satizabal-Reyes M, López-Salamanca DE, López-Paz Y, et al. Vulnerabilidad social y tuberculosis: un círculo vicioso. Entramado. 2022 Dec 15;19(1). Craig GM, Daftary A, Engel N, O’driscoll S, Ioannaki A. Tuberculosis stigma as a social determinant of health: a systematic mapping review of research in low incidence countries. International Journal of Infectious Diseases [Internet]. 2017 [cited 2023 Dec 26];56:90–100. Available from: http://dx.doi.org/10.1016/j.ijid.2016.10.011 Molina Y, Choi SW, Cella D, Rao D. The stigma scale for chronic illnesses 8-item version (SSCI-8): Development, validation and use across neurological conditions. Int J Behav Med [Internet]. 2013 Sep 26 [cited 2023 Dec 26];20(3):450–60. Available from: https://link.springer.com/article/10.1007/s12529-012-9243-4 Worgu GO, Onotai LO, Asuquo EO. Medication Adherence among Pulmonary Tuberculosis Patients in Treatment Centers in a Southern Nigerian Local Government Area: Question Mark on Performance of DOTS Services. Niger Med J [Internet]. 2023 [cited 2024 Dec 15];63(5):418. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11165329/ Bello SI, Itiola OA. Drug adherence amongst tuberculosis patients in the. Afr J Pharm Pharmacol [Internet]. 2010;4(3):109–14. Available from: http://www.academicjournals.org/ajpp Tesfahuneygn G, Medhin G, Legesse M. Adherence to Anti-tuberculosis treatment and treatment outcomes among tuberculosis patients in Alamata District, northeast Ethiopia. BMC Res Notes. 2015 Sep 29;8(1). Hassani S, Mohammadi Shahboulagi F, Foroughan M, Tabarsi P, Ghaedamini Harouni G, Jamaati H, et al. Relationship of family caregivers’ associated factors with medication adherence among elderly with tuberculosis in Iran. J Clin Tuberc Other Mycobact Dis. 2024 Dec 1;37. Garbrah BG, Abebrese J, Owusu-Marfo J. Factors associated with tuberculosis treatment adherence among tuberculosis patients in the Kumasi metropolis in the Ashanti Region of Ghana; A cross-sectional study. J Public Health (Bangkok). 2024 Dec 3;32(12):2353–64. Adisa R, Ayandokun TT, Ige OM. Knowledge about tuberculosis, treatment adherence and outcome among ambulatory patients with drug-sensitive tuberculosis in two directly-observed treatment centres in Southwest Nigeria. BMC Public Health. 2021 Dec 7;21(1):677. Sazali MF, Rahim SSSA, Mohammad AH, Kadir F, Payus AO, Avoi R, et al. Improving Tuberculosis Medication Adherence: The Potential of Integrating Digital Technology and Health Belief Model. Tuberc Respir Dis (Seoul). 2023 Apr 1;86(2):82–93. Ajema D, Shibru T, Endalew T, Gebeyehu S. Level of and associated factors for non-adherence to anti-tuberculosis treatment among tuberculosis patients in Gamo Gofa zone, southern Ethiopia: cross-sectional study. BMC Public Health. 2020 Dec 13;20(1):1705. Madukoma E, Olayemi OM. Assessment of Health-Related Quality of Life of Tuberculosis Patients in Lagos State, Nigeria. Epidemiology and Health System Journal. 2022 Nov 30;9(4):178–83. Chung WS, Lan YL, Yang MC. Psychometric testing of the short version of the world health organization quality of life (WHOQOL-BREF) questionnaire among pulmonary tuberculosis patients in Taiwan. BMC Public Health. 2012 Dec 9;12(1):630. Teo AKJ, Morishita F, Islam T, Viney K, Ong CWM, Kato S, et al. Tuberculosis in older adults: challenges and best practices in the Western Pacific Region. Lancet Reg Health West Pac. 2023 Jul;36:100770. Sukartini T, Hidayati L, Khoirunisa N. Knowledge, Family and Social Support, Self Efficacy and Self-Care Behaviour in Pulmonary Tuberculosis Patients. Jurnal Keperawatan Soedirman. 2019 Jul 10;14(2). Mukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Ann Glob Health. 2018 Nov 5;84(4):727. Aryal S, Badhu A, Pandey S, Bhandari A, Khatiwoda P, Khatiwada P, et al. Stigma Related to Tuberculosis Among Patients Attending DOTS Clinics of Dharan Municipality. Kathmandu University Medical Journal. 2012 Oct 2;10(1):40–3. Chowdhury MRK, Rahman MS, Mondal MNI, Sayem A, Billah B. Social Impact of Stigma Regarding Tuberculosis Hindering Adherence to Treatment: A Cross Sectional Study Involving Tuberculosis Patients in Rajshahi City, Bangladesh. Jpn J Infect Dis. 2015;68(6):461–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 31 Jul, 2025 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 09 Jun, 2025 Reviews received at journal 30 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers agreed at journal 09 May, 2025 Reviews received at journal 21 Apr, 2025 Reviewers agreed at journal 18 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviews received at journal 09 Apr, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviewers agreed at journal 05 Apr, 2025 Reviewers invited by journal 04 Apr, 2025 Editor assigned by journal 03 Apr, 2025 Submission checks completed at journal 03 Apr, 2025 First submitted to journal 03 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6187729","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446269387,"identity":"2e2fb317-85cb-4664-bb14-7a1cefcd443d","order_by":0,"name":"Michael Lahai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACZgbGA4wNEiAm4wMgwcNHhBYGmBZmA5AWNmIsAmoB02xgjQS16LYzPzjwc4eFPX/74WeVX3PsZNgYmB8+uoFHi9lhNoODvWckEmecSTO7LbstGegwNmPjHLxaeBgO8LZJJDAcyGG7LbmNGaiFh02akJaDf9sk7OXPv2ErltxWT5yWw0BbGDfcyGFj/LjtMDFa2AwOy7ZJJG688cxYmnHbcR42ZkJ+OX/44cO3bXX2cueTH378ua3anp+9+eFjfFpQADMPmCRWOQgw/iBF9SgYBaNgFIwYAADz60bLFdPgigAAAABJRU5ErkJggg==","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"","lastName":"Lahai","suffix":""},{"id":446269388,"identity":"9c413b09-b93d-4f6a-bbd1-45acb0e2c232","order_by":1,"name":"Sally-Mattu Conteh","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Sally-Mattu","middleName":"","lastName":"Conteh","suffix":""},{"id":446269389,"identity":"1e3eecf0-c76d-427e-a1ad-dff1c382ce18","order_by":2,"name":"Ahmed Vandy","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Vandy","suffix":""},{"id":446269390,"identity":"4615e164-0e8f-43e5-97b2-807412c184ed","order_by":3,"name":"Onome T Abiri","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Onome","middleName":"T","lastName":"Abiri","suffix":""},{"id":446269391,"identity":"139b8664-b02d-4412-a3b7-8807547c65b6","order_by":4,"name":"Brian Thompson","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Thompson","suffix":""},{"id":446269392,"identity":"809a3d4f-387d-48e6-9462-357edbcbbc8d","order_by":5,"name":"Mohamed Bawoh","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Bawoh","suffix":""},{"id":446269393,"identity":"a8cb760e-6429-411d-adcb-9eaa0d2a5694","order_by":6,"name":"Alvin Turay","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Alvin","middleName":"","lastName":"Turay","suffix":""},{"id":446269394,"identity":"00601548-9635-473a-8faf-55a00f64c2cd","order_by":7,"name":"Peter Bai James","email":"","orcid":"","institution":"University of Sierra Leone","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"Bai","lastName":"James","suffix":""}],"badges":[],"createdAt":"2025-03-09 09:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6187729/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6187729/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-025-00817-x","type":"published","date":"2025-07-31T16:39:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88268825,"identity":"9b96cd88-a223-48b5-b6d7-ec51aa57ab6a","added_by":"auto","created_at":"2025-08-04 16:52:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1117864,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6187729/v1/1c5f9f6f-c53b-45d6-81bb-8ef1278f90cd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Quality of Life, Adherence, and Stigmatization among People Receiving Anti-Tuberculosis Medications in Three Tertiary Hospitals in Sierra Leone: A Cross- Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculosis continues to pose a significant global public health challenge despite extensive efforts to control and treat the disease using cost-effective drugs and interventions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Each year, TB affects approximately 10\u0026nbsp;million individuals, with 1.5\u0026nbsp;million succumbing to the disease despite its preventable and treatable nature, making it one of the leading infectious causes of death globally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to the World Health Organization (WHO), approximately 480,000 people had multidrug-resistant TB (MDR-TB) in 2014, resulting in 190,000 deaths from this form of the disease (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Although the global TB incidence rate is declining, it is not on track to meet the 2020 target of a 20% decrease from 2015 to 2020. The total decrease from 2015 to 2019 was 9% (from 142 to 130 new cases per 100,000 people), with a 2.3% fall from 2018 to 2019 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the key obstacles to effective medical treatment is the patient's failure to adhere to the instructions and recommendations from their healthcare providers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Adherence is essential in treating tuberculosis to achieve the required treatment success rate (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, due to the long treatment duration (intense phase of two months and continuation phase of six to nine months) for newly diagnosed patients and (12 months or at most two years) for multi-drug resistance (MDR) patients, adherence to TB treatment is the most challenging factor affecting TB control (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Non-adherence can lead to poor treatment outcomes, relapse and development of multi-drug resistance Tuberculosis MDR-TB (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). According to WHO, Patients' adherence to their medication regimens has been reported to be influenced by the interaction of several factors which can be grouped as social and economic factors, health-care team and system-related factors, condition-related factors, therapy-related factors, and patient-related factors (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These factors that influence patient adherence to TB treatment vary in different populations. Those that emerged in our current study might be similar to, or different from, those reported in other areas in Sierra Leone. Currently, TB control programs focus on achieving microbiological cure as the main measure of successful treatment (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, this approach does not fully consider the physical, mental, and social impact of TB on patients. Patients may not only suffer from the symptoms of the disease but also experience a decline in their overall quality of life (QoL), which is believed to have a major influence on adherence and overall clinical outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Understanding the disease burden based on all predicted QoL domains is crucial, especially in low-income countries (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe stigma associated with TB also presents a major obstacle to TB control as it causes delays in diagnosis and non-compliance with treatment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The stigmatizing attitudes and behaviours of community members in low-income countries towards the disease may lead affected individuals to live in isolation, hide the diagnosis from others and default treatment (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). TB-related stigma and discrimination can lead to social exclusion, marginalization, and participatory restrictions on those suffering from the disease (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, health professionals and TB program staff in Sierra Leone have limited evidence on TB treatment adherence and barriers or enabling factors to treatment optimization. Our current study has determined the adherence to TB medication, the quality of life of TB patients, the association of socio-demographic factors to the quality of life, and the effect of stigmatization on people receiving anti-TB medications at three tertiary hospitals in Sierra Leone (Lakka hospital, Connaught hospital, and Kenema government hospital). The findings from this research will provide valuable insight into the challenges faced by TB patients in Sierra Leone and inform strategies to improve treatment outcomes and reduce the stigma associated with the disease.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design, setting and duration\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional facility-based study conducted between May to July 2021 at three tertiary hospitals in Sierra Leone: Kenema Government Hospital in the Eastern region, Lakka Hospital in the Western Area Rural, and Connaught Hospital in the Western Area Urban of Freetown. These hospitals are the main referral centres for TB care in two of the four regions of the country.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population and sample size\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of all patients aged 18 years and above who had been on anti-TB medication for more than four months and were attending the TB clinics at the selected hospitals. The sample size of 384 was calculated using Fisher's formula, n\u0026thinsp;=\u0026thinsp;z\u003csup\u003e2\u003c/sup\u003epq/d\u003csup\u003e2\u003c/sup\u003e, where n\u0026thinsp;=\u0026thinsp;sample size, p\u0026thinsp;=\u0026thinsp;0.05, assuming 50% of the overall population, z score of 1.96 that corresponds to a 95% confidence interval and an accepted error of 5%.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eAll TB patients aged 18 years and above who were actively on Antitubercular medications at these facilities for over four months of treatment were included in this study. Consent for participation was requested from all participants, and all participants were informed of their right to participate or refuse participation in the study at any time during the interview. Six patients at Lakka Hospital and four patients at Connaught Hospital were excluded from the study because they did not consent to participate in the study. Criteria for exclusion included; TB patients seeking temporal treatment from the facility and patients that are too sick or mentally incompetent to be interviewed.\u003c/p\u003e\n\u003ch3\u003eOutcome measures and data collection\u003c/h3\u003e\n\u003cp\u003eAn interviewer-administered questionnaire was used for data collection. The questionnaire had four sections: patients' Socio-demographic, patients' adherence Scale, TB-related Stigma questions, and quality of life questions. The dependent variables in this study were the four quality of life domains (Physical Health, Psychological Health, Environmental Health, and Social Health), which were measured using the WHO Quality of Life-BREF (WHOQOL-BREF) tool. Adherence was measured using the 8-Item Morisky adherence self-reporting tool. The first seven questions on the scale required a \u0026lsquo;Yes\u0026rsquo; or \u0026lsquo;No\u0026rsquo; response, while the last question utilized a five-point Likert scale \u0026ldquo;always,\u0026rdquo; \u0026ldquo;usually,\u0026rdquo; \u0026ldquo;sometimes,\u0026rdquo; \u0026ldquo;once in a while,\u0026rdquo; and \u0026ldquo;never\u0026rdquo;. We also adapted the 8-item Stigma Scale for Chronic Illnesses (SSCI) to assess stigmatization (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Data collectors were trained on the data collection procedure using an interviewer-administered format.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eReliability and validity of the instrument were checked by determining Cronbach's alpha value, for which an alpha value greater than or equal to 0.70 was deemed acceptable, while Pearson\u0026rsquo;s correlations above 0.4 were considered to be acceptable. Descriptive statistics were used to analyze categorical and continuous variables.\u003c/p\u003e \u003cp\u003eThe 8-item adherence assessment was scored as done in a similar study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e); the first seven questions were scored as 1 for each \u0026ldquo;Yes\u0026rdquo; response and 0 for \u0026ldquo;No\u0026rdquo; response. The last question which had the Likert scale was scored as 1 for \"never\u0026rdquo;, 0.75 for 'once in a while' and 'sometimes', while 'usually' was scored as 0.25 and 'all the time' was scored as 0. An aggregate score of the 8-item questions of 0 to less than 4 was categorized as adherent and 4 to 8 as non-adherent.\u003c/p\u003e \u003cp\u003eBivariate associations between independent variables and quality of life (transformed scores of four domains) were determined using an independent sample T-test and Analysis of Variance (ANOVA). Post hoc analysis was further conducted for domains that showed significant differences using backward multivariate linear regression, with a P-value less than 0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSocio-demographic and other related characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 provides detailed information about the sociodemographic distribution of the patients from the three hospitals, 160 (41.7%) were from Connaught Hospital, 152 (39.6%) from Lakka Hospital, and 72 (18.7%) came from Kenema Government Hospital. The mean age of the participants was 33.92 years. More than half of the patients were male living with an extended family. About 46.4% were married and 32.3% had no formal education. The overall treatment adherence level was 96.9%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Socio-demographic and other characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilities\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eConnaught Hospital\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLakka Hospital\u003c/p\u003e\n \u003cp\u003eKenema Government Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e160(41.7%)\u003c/p\u003e\n \u003cp\u003e152 (39.6%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72 (18.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt; 40years\u003c/p\u003e\n \u003cp\u003e\u0026ge; 40years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e280 (72.9)\u003c/p\u003e\n \u003cp\u003e104 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e226 (58.9)\u003c/p\u003e\n \u003cp\u003e158 (41.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChristianity\u003c/p\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e162 (42.2)\u003c/p\u003e\n \u003cp\u003e222 (57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003cp\u003eWidow/Widower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e167 (43.5)\u003c/p\u003e\n \u003cp\u003e178 (46.4)\u003c/p\u003e\n \u003cp\u003e15 (3.9)\u003c/p\u003e\n \u003cp\u003e24 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you have kids\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e272 (70.8)\u003c/p\u003e\n \u003cp\u003e112 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of family\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNuclear\u003c/p\u003e\n \u003cp\u003eSingle parent\u003c/p\u003e\n \u003cp\u003eExtended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e112 (29.2)\u003c/p\u003e\n \u003cp\u003e79 (20.6)\u003c/p\u003e\n \u003cp\u003e193 (50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003cp\u003eCollege (diploma above)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e124 (32.3)\u003c/p\u003e\n \u003cp\u003e75 (19.5)\u003c/p\u003e\n \u003cp\u003e116 (30.2)\u003c/p\u003e\n \u003cp\u003e69 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving arrangement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRent\u003c/p\u003e\n \u003cp\u003eOwn\u003c/p\u003e\n \u003cp\u003eStaying at a friend\u0026rsquo;s place\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e225 (58.6)\u003c/p\u003e\n \u003cp\u003e151 (39.3)\u003c/p\u003e\n \u003cp\u003e8 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily economic situation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57 (14.8)\u003c/p\u003e\n \u003cp\u003e226 (58.9)\u003c/p\u003e\n \u003cp\u003e101 (26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAdherent\u003c/p\u003e\n \u003cp\u003eNon-adherent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e372 (96.9)\u003c/p\u003e\n \u003cp\u003e12 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of quality of life among TB patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows the average transformed scores of the four different domains with the social domain [64.65(SD 15.6)] and the environmental relationship domain [58.18(SD 13.5)] being the highest and lowest mean scores respectively. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Transformed Quality of Life (QOL) Domain Scores (N=384)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQOL Domains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e62.43 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePsychological domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e59.47 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSocial relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e64.65 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eEnvironment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e58.18 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between the sociodemographic variables and Quality of life domains\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows the statistically significant difference\u0026nbsp;between the patient\u0026rsquo;s age and physical health (p = 0. 000), psychological health (p = 0.001) and Environmental health (p= 0.002) domains. There was also a statistically significant difference between the patient\u0026rsquo;s Religion and Environmental health domain (p= 0.000). Also, a significant difference was observed between the patient\u0026rsquo;s marital status, having kids and Family Economic Situation with all the four quality-of-life domains. In addition, there was a statistically significant difference between the type of family of the patient and the psychological health (p= 0.010) and environmental health (0.004) domains.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMultivariate backward linear regression model after adjusting for other covariates revealed a significant association between the patient\u0026rsquo;s age and physical, psychological and environmental health domains. A statistically significant association was seen between patients\u0026rsquo; family economic situation and the environmental health domains. There was also a significant association between the psychological health domain and those who had kids. A significant association was also seen between the social health domain and the patient\u0026rsquo;s marital status. This study also revealed a significant association between the environmental health domain and Patient\u0026rsquo;s religion (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Bivariate associations between independent variables and quality of life \u0026ndash; Independent Sample T-test and ANOVA.\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e \u003cstrong\u003eQuality of life Scores\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDom 1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean (SD) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDom 2 \u0026nbsp;Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eDom 3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean (SD) \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDom4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Age\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;40 years\u003c/p\u003e\n \u003cp\u003e\u0026ge; 40 years\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ep-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.5 (15.4)\u003c/p\u003e\n \u003cp\u003e56.8 (17.6)\u003c/p\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61.2 (16.4)\u003c/p\u003e\n \u003cp\u003e54.8 (15.4)\u003c/p\u003e\n \u003cp\u003e0.001***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65.0 (15.6)\u003c/p\u003e\n \u003cp\u003e63.7 (15.5)\u003c/p\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59.5 (13.7)\u003c/p\u003e\n \u003cp\u003e54.7 (12.4)\u003c/p\u003e\n \u003cp\u003e0.002***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Gender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003ep-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.4 (17.1)\u003c/p\u003e\n \u003cp\u003e62.5 (15.4)\u003c/p\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59.6 (17.0)\u003c/p\u003e\n \u003cp\u003e59.3 (15.4)\u003c/p\u003e\n \u003cp\u003e0.849\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.9 (16.7)\u003c/p\u003e\n \u003cp\u003e64.3 (13.9)\u003c/p\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58.4 (13.3)\u003c/p\u003e\n \u003cp\u003e57.8 (13.9)\u003c/p\u003e\n \u003cp\u003e0.675\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Religion\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChristianity\u003c/p\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.4 (15.9)\u003c/p\u003e\n \u003cp\u003e62.4 (16.8)\u003c/p\u003e\n \u003cp\u003e0.993\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60.6 (16.5)\u003c/p\u003e\n \u003cp\u003e58.7 (16.2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.3 (15.3)\u003c/p\u003e\n \u003cp\u003e64.9 (15.7)\u003c/p\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61.3 (13.3)\u003c/p\u003e\n \u003cp\u003e55.9 (13.2)\u003c/p\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Marital status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003cp\u003eWidow/Widower\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;66.2(15.5)\u003c/p\u003e\n \u003cp\u003e60.3(15.9)\u003c/p\u003e\n \u003cp\u003e58.3(14.8)\u003c/p\u003e\n \u003cp\u003e54.6(21.2)\u003c/p\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.6(17.3)\u003c/p\u003e\n \u003cp\u003e57.2(15.2)\u003c/p\u003e\n \u003cp\u003e59.2(15.4)\u003c/p\u003e\n \u003cp\u003e54.9(15.3)\u003c/p\u003e\n \u003cp\u003e0.008**\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67.5(15.7)\u003c/p\u003e\n \u003cp\u003e62.5(15.4)\u003c/p\u003e\n \u003cp\u003e62.2(15.7)\u003c/p\u003e\n \u003cp\u003e62.1(13.0)\u003c/p\u003e\n \u003cp\u003e0.018**\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60.8(12.8)\u003c/p\u003e\n \u003cp\u003e56.8(13.3)\u003c/p\u003e\n \u003cp\u003e55.4(17.2)\u003c/p\u003e\n \u003cp\u003e52.1(14.3)\u003c/p\u003e\n \u003cp\u003e0.003***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you have Kids\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61.2 (16.4)\u003c/p\u003e\n \u003cp\u003e65.4 (16.2)\u003c/p\u003e\n \u003cp\u003e0.024**\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57.6 (15.5)\u003c/p\u003e\n \u003cp\u003e63.9 (17.4)\u003c/p\u003e\n \u003cp\u003e0.001***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.3 (15.3)\u003c/p\u003e\n \u003cp\u003e67.9 (15.9)\u003c/p\u003e\n \u003cp\u003e0.009**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57.0 (13.7)\u003c/p\u003e\n \u003cp\u003e61.0 (12.8)\u003c/p\u003e\n \u003cp\u003e0.008**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Family\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNuclear\u003c/p\u003e\n \u003cp\u003eSingle parent\u003c/p\u003e\n \u003cp\u003eExtended\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.3(15.0)\u003c/p\u003e\n \u003cp\u003e63.2(14.7)\u003c/p\u003e\n \u003cp\u003e61.6(17.8)\u003c/p\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58.0(18.0)\u003c/p\u003e\n \u003cp\u003e64.4(13.1)\u003c/p\u003e\n \u003cp\u003e58.3(16.2)\u003c/p\u003e\n \u003cp\u003e0.010**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.5(16.3)\u003c/p\u003e\n \u003cp\u003e65.4(13.9)\u003c/p\u003e\n \u003cp\u003e65.0(15.8)\u003c/p\u003e\n \u003cp\u003e0.658\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60.3(14.4)\u003c/p\u003e\n \u003cp\u003e60.8(13.1)\u003c/p\u003e\n \u003cp\u003e55.9(12.8)\u003c/p\u003e\n \u003cp\u003e0.004***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving Arrangement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRent\u003c/p\u003e\n \u003cp\u003eOwn\u003c/p\u003e\n \u003cp\u003eStaying at a friend\u0026rsquo;s place\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.8(16.1)\u003c/p\u003e\n \u003cp\u003e62.0(16.7)\u003c/p\u003e\n \u003cp\u003e59.4(22.4)\u003c/p\u003e\n \u003cp\u003e0.765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58.7(16.6)\u003c/p\u003e\n \u003cp\u003e61.1(15.6)\u003c/p\u003e\n \u003cp\u003e50.5(21.0)\u003c/p\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.7(16.1)\u003c/p\u003e\n \u003cp\u003e64.7(14.3)\u003c/p\u003e\n \u003cp\u003e60.4(22.6)\u003c/p\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57.3(13.6)\u003c/p\u003e\n \u003cp\u003e60.0(13.2)\u003c/p\u003e\n \u003cp\u003e54.3(15.8)\u003c/p\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Economic Situation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGood \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66.5(15.0)\u003c/p\u003e\n \u003cp\u003e63.0(15.1)\u003c/p\u003e\n \u003cp\u003e58.9(19.1)\u003c/p\u003e\n \u003cp\u003e0.014**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60.0(17.0)\u003c/p\u003e\n \u003cp\u003e61.4(15.9)\u003c/p\u003e\n \u003cp\u003e55.0(16.3)\u003c/p\u003e\n \u003cp\u003e0.004***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65.2(17.1)\u003c/p\u003e\n \u003cp\u003e67.0(15.0)\u003c/p\u003e\n \u003cp\u003e59.1(14.6)\u003c/p\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66.3(12.4)\u003c/p\u003e\n \u003cp\u003e60.2(12.2)\u003c/p\u003e\n \u003cp\u003e49.0(12.1)\u003c/p\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence Level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAdherent\u003c/p\u003e\n \u003cp\u003eNon-Adherent\u003c/p\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.2 (16.4)\u003c/p\u003e\n \u003cp\u003e68.5 (15.0)\u003c/p\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59.6 (16.3)\u003c/p\u003e\n \u003cp\u003e55.2 (16.9)\u003c/p\u003e\n \u003cp\u003e0.359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64.5 (15.7)\u003c/p\u003e\n \u003cp\u003e68.1 (11.7)\u003c/p\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58.1 (13.4)\u003c/p\u003e\n \u003cp\u003e60.9 (16.2)\u003c/p\u003e\n \u003cp\u003e0. 473\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003eDom1: Physical Health; Dom2: Psychological Health; Dom3: Social Health; Dom4: environmental Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Backward multiple linear regression analyses of factors significantly associated with quality of life of Patients with TB\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"679\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eQuality of life scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eDom 1\u003c/p\u003e\n \u003cp\u003eCoef/P-value (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eDom 2\u003c/p\u003e\n \u003cp\u003eCoef/P-value (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eDom 3\u003c/p\u003e\n \u003cp\u003eCoef/P-value (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eDom 4\u003c/p\u003e\n \u003cp\u003eCoef/P-value (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Age\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;40 vs \u0026nbsp;\u0026gt;/=40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-7.669/0.000\u003c/p\u003e\n \u003cp\u003e(-11.296, -4.042)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-4.720/0.017\u003c/p\u003e\n \u003cp\u003e(-8.603, -0.838)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-4.172/0.005\u003c/p\u003e\n \u003cp\u003e(-7.080,-1.264)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you have kids\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.636/0.017\u003c/p\u003e\n \u003cp\u003e(0.840, 8.432)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMarried vs Not married\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.242/0.008\u003c/p\u003e\n \u003cp\u003e(1.139, 7.346)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s Religion\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChristianity vs Islam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-4.750/0.000\u003c/p\u003e\n \u003cp\u003e(-7.375, -2.124)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Economic Situation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGood vs Not Good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-8.087/0.000\u003c/p\u003e\n \u003cp\u003e(-11.755, -4.420)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 679px;\"\u003e\n \u003cp\u003eDom1: Physical Health; Dom2: Psychological Health; Dom3: Social Health; Dom4: Environmental Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eStigma scale responses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of the participants (70.6%) were always unhappy about how TB affected their appearance, and 55.2% avoided others for fear that they might infect them with TB. Moreover, 48.7% were certain of their recovery. More than half of the participants were always careful about whom they told they had TB, and 23.6% were worried that some people assumed they had HIV because they had TB. The result also showed that 25.5% said some people did not support them (physically/emotionally/financially) because they have TB (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u0026nbsp;\u003c/strong\u003eTB Stigma Scale\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eQuestions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eDisagree N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUncertain N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAgree N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eWere you unhappy about how TB affected your appearance?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e36(9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e77(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e271(70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eDid you avoid others for fear that you will infect them with TB?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e83(21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e89(23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e212(55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eAre you afraid that you will not recover from TB or that you will die?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e187(48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e82(21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e115(30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eDid you worry that you were a burden to others?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e169(44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e116(30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e99(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eAre you careful about who you tell you have TB?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e52(13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e102(26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e230(59.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eDid you worry that some people assumed that you have HIV because you have TB?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e203(52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e80(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e101(26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eDid some people avoid/keep their distance from you, for fear of infecting them with TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e161(41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e109(28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e114(29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eDid some people not support you (physically/emotionally/financially) because you have TB?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e156(40.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e130(33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e98(25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eYes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNo (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e8a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eSpouse/Boyfriend/Girlfriend, He /She rejected me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e50 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e334 (87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e8b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 267px;\"\u003e\n \u003cp\u003eOther family member(s), some rejected me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e24 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e360 (93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study provides valuable information for TB patients receiving antituberculosis medications with an emphasis on 3 key areas of emphasis that include Adherence to TB medication, Quality of life assessment and the association of demographic factors to quality of life and the Stigmatization of TB patients on anti-TB medication.\u003c/p\u003e \u003cp\u003eMost of the patients in this study were adherent to their TB treatment regimen, which aligns with the findings from the University of Ilorin Teaching Hospital, Ilorin, Nigeria and Alamata District, northeast Ethiopia where 94.6% and 88.5% of the patients undergoing TB treatment were adherent (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This high adherence rate, while encouraging, contrasts with some studies reporting lower adherence rates in other settings, such as Iran (27.54%) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and Ghana (76.8%) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This could potentially be attributed to effective Directly Observed Therapy (DOTS) programs implemented in our study sites, although further investigation is needed to confirm this. Continuous monitoring and evaluation are needed to maintain and further improve adherence rates at these facilities. TB is curable if treatment starts quickly, monitored and is consistent throughout the 6\u0026ndash;9 month treatment duration (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, high default rates, interruptions, and lack of adherence, along with insufficient disease knowledge often lead to poor outcomes, particularly in developing countries. Non-adherence in TB treatment is a major concern as it has reportedly led to TB drug resistance which prolongs the infectiousness of the disease and increases the relapse and death of patients (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe result from our assessment of the quality of life of TB patients revealed a higher mean score in the social health domain and the physical health domain, while the lowest mean score was observed in the environmental health domain. These findings suggest that while patients may have been coping well with their physical health and social relationships, environmental factors (such as living conditions, availability of healthcare facilities, and community support) and psychological health remain areas of concern, especially in our resource-constrained settings. Similar findings were also reported in a study done in Nigeria, where the environmental domain had the lowest QoL score (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Patients with infectious TB may require hospitalization or isolation from the community, leading to not only health issues related to the disease but also psychological distress, stigma and withdrawal from environmental interaction (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Unlike settings with robust socioeconomic support structures, the economic strain in our resource-limited settings can significantly impact environmental domains, underscoring the need for structural interventions in Sierra Leone.\u003c/p\u003e \u003cp\u003eThe bivariate associations revealed that age, marital status, those with kids, patient's religion, type of family, and family economic situation were statistically significant factors associated with patient QoL. After adjusting for other covariates, a backward multiple linear regression model showed that patient age, marital status, having kids, religion and family economic situation were statistically significant factors associated with patient QoL. For instance, patients aged less than 40 years had better physical, psychological and environmental health than older patients aged above 40 years. Younger individuals may have better resilience and coping strategies. Older patients with TB are also more likely to have adverse outcomes than younger patients, and they may face additional challenges in coping with the effects of the disease and adhering to treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Additionally, the analysis indicated that marital status, having children, and the family's economic situation significantly impacted QoL, highlighting the importance of social support and economic stability in health outcomes. The study by Sukartini et al. supports the current study's findings on the importance of family support in the management of tuberculosis patients (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Although religion was significantly associated with the environmental health domain in our study, this finding warrants further exploration to understand the underlying mechanisms.\u003c/p\u003e \u003cp\u003eThe assessment of stigmatization revealed concerning findings. A substantial proportion of participants expressed unhappiness about how TB affected their appearance, avoided others due to fear of transmission, and were careful about disclosing their diagnosis. As stigmatization remains a significant barrier for TB patients, understanding how individuals with TB feel and cope with the stigma associated with the disease plays a vital role in understanding their health-seeking behaviour and adherence (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). It leads to social isolation, negatively impacting mental and physical health. Hindering disclosure of infections, and undermines TB screening efforts (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). For instance, the fear of being perceived as having HIV due to TB is particularly of concern in our study, as it may deter individuals from seeking timely medical help, further perpetuating the cycle of transmission and morbidity. We also highlighted the social stigma attached to TB by considering two important indicators that explained TB stigma in Sierra Leone. These indicators included rejection from their spouse and rejection from other family members. The proportion of participants who reported social rejection in our study is low relative to those observed in previous studies done in Nepal and Bangladesh (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Counselling and support services should be provided to families of TB patients in these settings to address concerns about transmission, promote understanding, and prevent rejection. As stigma decreases self-esteem and quality of life in patients, sensitization can play a great role in combating how the society perceives and treats TB patients. This information about TB stigmatization can provide vital insights into how TB is experienced by the persons affected by TB and also help TB programs and healthcare providers provide person-centred approaches instead of disease-centred care.\u003c/p\u003e \u003cp\u003eThere is the need for continued stigma sensitization of communities with TB patients, assigning pharmacists to TB facilities for counselling patients and identification of patients that have been lost to follow-up or have the potential to be lost to follow-up. To improve treatment uptake, rural communities should be educated about the availability of treatment for TB and its potential benefits in combating the disease. A detailed study should be instituted to help understand TB's prevalence and actual threat level in the country. We recommend the need for the TB program to team up with accredited community pharmacists in various communities to provide medications at affordable prices without having to go to the hospitals for a refill.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has some limitations. The result of this study may not be used to generalize the whole population of TB patients in Sierra Leone because of the small sample size that was focused on clinic attendance during the period of study. The reliance on self-reported data may be subject to recall bias and social desirability bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile adherence rates remain encouraging among TB patients, significant gaps in psychological and environmental Quality of life domains, along with pervasive stigma, demand urgent public health interventions. As the disease presents with a multidimensional health burden, strengthening family support systems, alleviating economic hardships, and addressing stigma through education and advocacy are essential multidimensional approaches for improving outcomes among TB patients. While treating the physical burden of the disease, policy initiatives should also focus on enhancing social support, providing psychological counselling, and addressing socio-economic disparities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTuberculosis (TB)\u003c/p\u003e\n\u003cp\u003emulti-drug resistance (MDR)\u003c/p\u003e\n\u003cp\u003emulti-drug resistance Tuberculosis MDR-TB\u003c/p\u003e\n\u003cp\u003eWHO Quality of Life-BREF (WHOQOL-BREF)\u003c/p\u003e\n\u003cp\u003eStigma Scale for Chronic Illnesses (SSCI)\u003c/p\u003e\n\u003cp\u003eAnalysis of Variance (ANOVA)\u003c/p\u003e\n\u003cp\u003eDirectly Observed Therapy (DOTS)\u003c/p\u003e\n\u003cp\u003eQuality of life (QoL)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical Approval to conduct this study was obtained from the College of Medicine and Allied Health Sciences Institutional Ethics Review Board with review number COMAHS/IRB/007-2024. A letter requesting permission for data collection was sent to the hospital care manager of the three hospitals. The purpose of the study was well explained to the participants and their right to participate voluntarily. Participants were also informed that they have the right to participate or refuse participation at any time during the interview without any consequences. Informed consent was obtained from all respondents before the commencement of the interview and only those who consented were interviewed. All the patient data were kept confidential and anonymously used for this study. Ethical requirement was met throughout the research in compliance with the Helsinki declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll datasets and reports used are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests whatsoever.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was self-funded by the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript. SC and ML developed the concept and proposal of the study. ML, AV, OTA, BT and PBJ provided guidance on research methods. AV, SC, ML and OTA facilitated data collection and analysed the dataset. AV, MB and SC prepared documents and framework for ethical approval and consent for the study. SC prepared the write-up and ML, AV, AT, BT and OTA provided expert review. AV, ML, OTA, MB and PBJ finalised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere thanks and appreciation to all those who participated in this research. We express our thanks to all the hospital care managers where this study was conducted, with special appreciation to the\u0026nbsp;coordinators and staff of the Lakka Government Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHaileamlak A. Tuberculosis Continued as Global Challenge Though the Burden Remained High in Low-Income and High-Income Countries. Ethiop J Health Sci [Internet]. 2018 Sep 1 [cited 2023 Dec 24];28(5):517. Available from: /pmc/articles/PMC6308771/\u003c/li\u003e\n\u003cli\u003eAnuwatnonthakate A, Limsomboon P, Nateniyom S, Wattanaamornkiat W, Komsakorn S, Moolphate S, et al. Directly Observed Therapy and Improved Tuberculosis Treatment Outcomes in Thailand. PLoS One [Internet]. 2008 Aug 28 [cited 2023 Dec 24];3(8):e3089. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0003089\u003c/li\u003e\n\u003cli\u003eAlimi N, Sakhi R. Knowledge, Attitude, and Practices Toward Tuberculosis Among Health Faculty and Non-Health Faculty Students of Kabul University and Kabul University of Medical Sciences, Kabul, Afghanistan. Adv Med Educ Pract [Internet]. 2023 [cited 2023 Dec 24];14:753. Available from: /pmc/articles/PMC10353910/\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Progress towards global TB targets \u0026ndash; an overview. Global Tuberculosis Report 2020 [Internet]. 2020 [cited 2023 Dec 24];Chapter 2.2, 7. Available from: http://apps.who.int/bookorders.\u003c/li\u003e\n\u003cli\u003eCheon SA, Cho HH, Kim J, Lee J, Kim HJ, Park TJ. Recent tuberculosis diagnosis toward the end TB strategy. J Microbiol Methods. 2016 Apr 1;123:51\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eJimmy B, Jose J. Patient Medication Adherence: Measures in Daily Practice. Oman Med J [Internet]. 2011 [cited 2023 Dec 26];26(3):155. Available from: /pmc/articles/PMC3191684/\u003c/li\u003e\n\u003cli\u003eBatte C, Namusobya MS, Kirabo R, Mukisa J, Adakun S, Katamba A. Prevalence and factors associated with non-adherence to multi-drug resistant tuberculosis (MDR-TB) treatment at Mulago National Referral Hospital, Kampala, Uganda. Afr Health Sci [Internet]. 2021 Mar 1 [cited 2023 Dec 25];21(1):238. Available from: /pmc/articles/PMC8356628/\u003c/li\u003e\n\u003cli\u003eAjema D, Shibru T, Endalew T, Gebeyehu S. Level of and associated factors for non-adherence to anti-tuberculosis treatment among tuberculosis patients in Gamo Gofa zone, southern Ethiopia: cross-sectional study. BMC Public Health [Internet]. 2020 Dec 1 [cited 2023 Dec 25];20(1):1\u0026ndash;9. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09827-7\u003c/li\u003e\n\u003cli\u003eBea S, Lee H, Kim JH, Jang SH, Son H, Kwon JW, et al. Adherence and Associated Factors of Treatment Regimen in Drug-Susceptible Tuberculosis Patients. Front Pharmacol [Internet]. 2021 Mar 15 [cited 2023 Dec 25];12. Available from: /pmc/articles/PMC8005597/\u003c/li\u003e\n\u003cli\u003eFernandez-Lazaro CI, Garc\u0026iacute;a-Gonz\u0026aacute;lez JM, Adams DP, Fernandez-Lazaro D, Mielgo-Ayuso J, Caballero-Garcia A, et al. Adherence to treatment and related factors among patients with chronic conditions in primary care: A cross-sectional study. BMC Fam Pract [Internet]. 2019 Sep 14 [cited 2023 Dec 26];20(1):1\u0026ndash;12. Available from: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-019-1019-3\u003c/li\u003e\n\u003cli\u003eAggarwal AN. Quality of life with tuberculosis. J Clin Tuberc Other Mycobact Dis. 2019 Dec 1;17:100121. \u003c/li\u003e\n\u003cli\u003eMalik M, Nasir R, Hussain A. Health Related Quality of Life among TB Patients: Question Mark on Performance of TB DOTS in Pakistan. J Trop Med. 2018;2018. \u003c/li\u003e\n\u003cli\u003eJuliasih NN, Mertaniasih NM, Hadi C, Soedarsono, Sari RM, Alfian IN. \u0026lt;p\u0026gt;Factors Affecting Tuberculosis Patients\u0026amp;rsquo; Quality of Life in Surabaya, Indonesia\u0026lt;/p\u0026gt;. J Multidiscip Healthc [Internet]. 2020 Nov 4 [cited 2023 Dec 26];13:1475\u0026ndash;80. Available from: https://www.dovepress.com/factors-affecting-tuberculosis-patientsrsquo-quality-of-life-in-suraba-peer-reviewed-fulltext-article-JMDH\u003c/li\u003e\n\u003cli\u003ePokam BDT, Fokam P, Njamen TN, Guemdjom PW, Asuquo AE, Pokam BDT, et al. Assessment of Health-Related Quality of Life of Tuberculosis Patients in Fako Division, South-West Region of Cameroon. J Tuberc Res [Internet]. 2020 Jul 13 [cited 2023 Dec 26];8(3):93\u0026ndash;110. Available from: http://www.scirp.org/journal/PaperInformation.aspx?PaperID=101462\u003c/li\u003e\n\u003cli\u003eChen X, Du L, Wu R, Xu J, Ji H, Zhang Y, et al. Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study. BMC Public Health [Internet]. 2021 Dec 1 [cited 2023 Dec 26];21(1):1\u0026ndash;10. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-10055-2\u003c/li\u003e\n\u003cli\u003eTadesse S. Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia. PLoS One [Internet]. 2016 Apr 1 [cited 2023 Dec 26];11(4). Available from: /pmc/articles/PMC4824500/\u003c/li\u003e\n\u003cli\u003eMukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Ann Glob Health [Internet]. 2018 Nov 5 [cited 2023 Dec 26];84(4):727. Available from: /pmc/articles/PMC6748300/\u003c/li\u003e\n\u003cli\u003eOrtiz-Ruiz N, D\u0026iacute;az-Grajales C, Zamudio-Espinosa D, Satizabal-Reyes M, L\u0026oacute;pez-Salamanca DE, L\u0026oacute;pez-Paz Y, et al. Vulnerabilidad social y tuberculosis: un c\u0026iacute;rculo vicioso. Entramado. 2022 Dec 15;19(1). \u003c/li\u003e\n\u003cli\u003eCraig GM, Daftary A, Engel N, O\u0026rsquo;driscoll S, Ioannaki A. Tuberculosis stigma as a social determinant of health: a systematic mapping review of research in low incidence countries. International Journal of Infectious Diseases [Internet]. 2017 [cited 2023 Dec 26];56:90\u0026ndash;100. Available from: http://dx.doi.org/10.1016/j.ijid.2016.10.011\u003c/li\u003e\n\u003cli\u003eMolina Y, Choi SW, Cella D, Rao D. The stigma scale for chronic illnesses 8-item version (SSCI-8): Development, validation and use across neurological conditions. Int J Behav Med [Internet]. 2013 Sep 26 [cited 2023 Dec 26];20(3):450\u0026ndash;60. Available from: https://link.springer.com/article/10.1007/s12529-012-9243-4\u003c/li\u003e\n\u003cli\u003eWorgu GO, Onotai LO, Asuquo EO. Medication Adherence among Pulmonary Tuberculosis Patients in Treatment Centers in a Southern Nigerian Local Government Area: Question Mark on Performance of DOTS Services. Niger Med J [Internet]. 2023 [cited 2024 Dec 15];63(5):418. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11165329/\u003c/li\u003e\n\u003cli\u003eBello SI, Itiola OA. Drug adherence amongst tuberculosis patients in the. Afr J Pharm Pharmacol [Internet]. 2010;4(3):109\u0026ndash;14. Available from: http://www.academicjournals.org/ajpp\u003c/li\u003e\n\u003cli\u003eTesfahuneygn G, Medhin G, Legesse M. Adherence to Anti-tuberculosis treatment and treatment outcomes among tuberculosis patients in Alamata District, northeast Ethiopia. BMC Res Notes. 2015 Sep 29;8(1). \u003c/li\u003e\n\u003cli\u003eHassani S, Mohammadi Shahboulagi F, Foroughan M, Tabarsi P, Ghaedamini Harouni G, Jamaati H, et al. Relationship of family caregivers\u0026rsquo; associated factors with medication adherence among elderly with tuberculosis in Iran. J Clin Tuberc Other Mycobact Dis. 2024 Dec 1;37. \u003c/li\u003e\n\u003cli\u003eGarbrah BG, Abebrese J, Owusu-Marfo J. Factors associated with tuberculosis treatment adherence among tuberculosis patients in the Kumasi metropolis in the Ashanti Region of Ghana; A cross-sectional study. J Public Health (Bangkok). 2024 Dec 3;32(12):2353\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eAdisa R, Ayandokun TT, Ige OM. Knowledge about tuberculosis, treatment adherence and outcome among ambulatory patients with drug-sensitive tuberculosis in two directly-observed treatment centres in Southwest Nigeria. BMC Public Health. 2021 Dec 7;21(1):677. \u003c/li\u003e\n\u003cli\u003eSazali MF, Rahim SSSA, Mohammad AH, Kadir F, Payus AO, Avoi R, et al. Improving Tuberculosis Medication Adherence: The Potential of Integrating Digital Technology and Health Belief Model. Tuberc Respir Dis (Seoul). 2023 Apr 1;86(2):82\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eAjema D, Shibru T, Endalew T, Gebeyehu S. Level of and associated factors for non-adherence to anti-tuberculosis treatment among tuberculosis patients in Gamo Gofa zone, southern Ethiopia: cross-sectional study. BMC Public Health. 2020 Dec 13;20(1):1705. \u003c/li\u003e\n\u003cli\u003eMadukoma E, Olayemi OM. Assessment of Health-Related Quality of Life of Tuberculosis Patients in Lagos State, Nigeria. Epidemiology and Health System Journal. 2022 Nov 30;9(4):178\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eChung WS, Lan YL, Yang MC. Psychometric testing of the short version of the world health organization quality of life (WHOQOL-BREF) questionnaire among pulmonary tuberculosis patients in Taiwan. BMC Public Health. 2012 Dec 9;12(1):630. \u003c/li\u003e\n\u003cli\u003eTeo AKJ, Morishita F, Islam T, Viney K, Ong CWM, Kato S, et al. Tuberculosis in older adults: challenges and best practices in the Western Pacific Region. Lancet Reg Health West Pac. 2023 Jul;36:100770. \u003c/li\u003e\n\u003cli\u003eSukartini T, Hidayati L, Khoirunisa N. Knowledge, Family and Social Support, Self Efficacy and Self-Care Behaviour in Pulmonary Tuberculosis Patients. Jurnal Keperawatan Soedirman. 2019 Jul 10;14(2). \u003c/li\u003e\n\u003cli\u003eMukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Ann Glob Health. 2018 Nov 5;84(4):727. \u003c/li\u003e\n\u003cli\u003eAryal S, Badhu A, Pandey S, Bhandari A, Khatiwoda P, Khatiwada P, et al. Stigma Related to Tuberculosis Among Patients Attending DOTS Clinics of Dharan Municipality. Kathmandu University Medical Journal. 2012 Oct 2;10(1):40\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eChowdhury MRK, Rahman MS, Mondal MNI, Sayem A, Billah B. Social Impact of Stigma Regarding Tuberculosis Hindering Adherence to Treatment: A Cross Sectional Study Involving Tuberculosis Patients in Rajshahi City, Bangladesh. Jpn J Infect Dis. 2015;68(6):461\u0026ndash;6. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Quality of life, adherence, stigmatization, Antituberculosis medicines, Sierra Leone","lastPublishedDoi":"10.21203/rs.3.rs-6187729/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6187729/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTuberculosis (TB) remains a significant public health concern, particularly in resource-limited settings, where the burden of TB is compounded by socioeconomic challenges and stigmatization. This study assessed the quality of life, treatment adherence, and stigmatization among patients receiving anti-TB medications in three tertiary hospitals in Sierra Leone.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA cross-sectional study of 384 patients at Connaught, Lakka, and Kenema government hospitals was conducted between May to July 2021. Data was collected using a structured pre-tested questionnaire, consisting of the Morisky adherence scale, WHO Quality of Life tool, and Stigma Scale for Chronic Illnesses to measure adherence, quality of life and stigma respectively. Data was analyzed using descriptive and inferential statistics using the Statistical Package for Social Sciences 16. Associations between independent variables and quality of life were determined using an independent sample T-test and ANOVA. Post hoc analysis was further conducted for variables that were significant using backward multivariate linear regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMore than half of the patients were male with a mean age of 33.92 years. The overall adherence rate among the patients in our study was 96.9%. The social relationship domain (64.65, SD\u0026thinsp;=\u0026thinsp;15.6) recorded the highest Quality of Life score, while the environmental health domain (58.18, SD\u0026thinsp;=\u0026thinsp;13.5) was the lowest. The result of the backward multivariate linear regression revealed patient age to be statistically significant with the physical Health (P-value\u0026thinsp;=\u0026thinsp;0.000), psychological Health (P-value\u0026thinsp;=\u0026thinsp;0.017) and environmental health domains (P-value\u0026thinsp;=\u0026thinsp;0.005). Having kids, Marital status, religion, and family economic situation were also found to be statistically significant with various other individual quality of life domains. The stigma indicators in this study were low with 24 (6.3%) and 50 (13.0%) of the patients reporting rejection from spouse and other family members respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite the study revealed an encouraging adherence rate, gaps in the psychological and environmental quality of life, along with stigma, require urgent public health action. Enhancing family support, reducing economic burdens, and combating stigma through public sensitization is crucial for better outcomes for TB patients.\u003c/p\u003e","manuscriptTitle":"Assessment of Quality of Life, Adherence, and Stigmatization among People Receiving Anti-Tuberculosis Medications in Three Tertiary Hospitals in Sierra Leone: A Cross- Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-24 18:28:08","doi":"10.21203/rs.3.rs-6187729/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-09T18:02:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-30T14:26:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131430907070466536918211768280258285709","date":"2025-05-14T02:27:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229587805486998461442354321283919115762","date":"2025-05-11T12:31:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59213722836951752631695608742250063887","date":"2025-05-09T17:57:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-21T20:58:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268548999136423730927587845886750441729","date":"2025-04-18T10:28:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305547813247859707878400673921047184204","date":"2025-04-17T18:53:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-09T19:24:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310781030723586607140175878556835746040","date":"2025-04-07T17:24:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24230906391955376518338959329434178101","date":"2025-04-05T20:15:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-04T06:23:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-03T16:28:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-03T14:21:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-04-03T14:20:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e56c53cd-86fc-4afb-b841-e22513d602d1","owner":[],"postedDate":"April 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:48:20+00:00","versionOfRecord":{"articleIdentity":"rs-6187729","link":"https://doi.org/10.1186/s12982-025-00817-x","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-07-31 16:39:18","publishedOnDateReadable":"July 31st, 2025"},"versionCreatedAt":"2025-04-24 18:28:08","video":"","vorDoi":"10.1186/s12982-025-00817-x","vorDoiUrl":"https://doi.org/10.1186/s12982-025-00817-x","workflowStages":[]},"version":"v1","identity":"rs-6187729","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6187729","identity":"rs-6187729","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}