African migrants and TB in Aotearoa New Zealand: The role of individual, social, economic and structural factors
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The post 2015 tuberculosis (TB) strategy by the World Health Organisation (WHO), “Towards TB elimination”, which is aimed at eliminating TB by 2050, has brought with it a new sense of urgency to eliminate TB in low-incidence countries. To attain these targets demands more focus and targeted interventions for the populations most at risk of TB, such as migrants. Migrants living in low incidence countries, including New Zealand (NZ), are disproportionately affected by TB and remain an important challenge to achieving TB elimination targets. This thesis sought to contribute to the control of TB among migrants by answering the questions: what is the epidemiology of TB including that of African migrants living in NZ and; what factors contribute to the relatively high rate of TB among this group? To answer these questions, a sequential explanatory mixed method approach, framed within a critical realist perspective, was employed in two phases. Phase I involved a descriptive epidemiological analysis of national TB surveillance data, 2010-2014. In the second phase of the study, participants were purposively sampled and interviewed one on one using a semi-structured approach. A hybrid thematic data analysis method was used in the analysis of the interview data. The analysis from phase I showed that NZ is unlikely to achieve the TB elimination target by 2050. The findings demonstrated that between 2010-2014, Africans living in NZ had the highest cumulative incidence rate of TB (24.3 per 100,000) compared to other foreign (21.75 per100,000) and NZ born (1.96 per 100,000). It further showed that African migrants living in NZ diagnosed with TB were more likely to be notified within the first year of arrival, commonly originated from the southern Africa region, and were commonly unemployed (20%), healthcare workers (14.1%) and students (10.6%). The interviews with participants offered some explanation for the observed TB epidemiology. The interview data suggest that many Africans may go through difficult settlement challenges within the first few years of arrival and with that an increased risk of TB reactivating. The findings further suggest that TB may invoke a double stigma within the African community due to its link with HIV. In addition, structural factors such as the immigration NZ policy, mistrust of healthcare providers and cost contribute to delays or non-reporting of symptoms suggestive of TB. This thesis demonstrates that TB incidence among Africans is more likely the outcome of a complex interplay between several factors including, individual, economic, social and structural. Hence, interventions aimed at TB prevention and elimination must holistically address the underlying factors, and avoid a fragmented approach that tends to emphasise the biomedical approaches.