La conformación de sindicatos y su repercusión en el sector agrario

Given a rate of almost 40% of patients having poor adherence, practical, yet simple guidelines on strategies to manage adherence are important. These may include guidelines on ongoing counselling for adherence to prescribed doses, monitoring and follow-up, and methods to identify the influential factors associated with adherence (Martins et al., 2009). Furthermore, incentives of reimbursement of travel cost and the expenses of attending treatment centers, and ongoing financial support for patients who struggle with financial security are likely encourage and attract patients, thereby reducing the chance of missing appointments and scheduled drug replenishment. Despite the results of the randomized control trial study in Timor-Leste indicating that food incentives had no significant benefits for TB treatment (Martins et al., 2009), studies from other settings have demonstrated the importance of food incentives on the overall outcome (Baldwin et al., 2004; Gupta et al., 2009; Ramakrishnan et al.,

1961). Martins et al. (2009) may not have found a correlation due to geographical location, because patients who participated in the study had been undertaking treatment in Dili, where food is plentiful compared to remote areas of the country. Evidence suggested that nutritional support showed more rapid clearance of bacteria and radiographic changes in addition to greater weight gain. Hence, nutritional supplementation assists patients in a fast recovery, particularly in underdeveloped areas of the world where food is scarce, and it may be an effective measure of TB control (Ramakrishnan et al., 1961).

The present study found that alcohol consumption impacted on adherence, and of the 12.7% that drank while under treatment, it was more common with men (72.7%) than women (27.3%) in Timor-Leste. Therefore, it is recommended that the national TB care and treatment program should assist patients with alcohol issues. Counselling and special treatment can be offered in an attempt to reduce alcohol intake during treatment.

It is crucial to provide effective counselling and treatment of patients with depressive symptoms, given the likely severity of its effect on adherence. Depression is common among patients with chronic medical illness, such as diabetes, HIV/AIDS and TB (Adem et al., 2014; Ciechanowski, Katon, & Russo, 2000; Patel, Simon, Chowdhary, Kaaya, & Araya, 2009). The findings of the current study indicate that most often, patients experience constant pressure as a result of having TB. Such feeling may cause them to feel guilty and blame themselves for having the disease (Nyblade et al., 2003). Adem et al. (2014) suggested that TB treatment and care should incorporate psychiatric co- morbidities to achieve the treatments’ primary outcomes. Another study also suggested that treatment, such as antidepressants and psychotherapy are effective and should be integrated into primary care in managing depression in low and middle income countries (Adem et al., 2014). Furthermore, Peltzer et al. (2012) suggested training of providers to improve necessary skills in screening adult patients with sign of depression, anxiety, and able to assist with referral and treatment intervention is important. To provide a conceptual model for health behaviour, a number of psychosocial constructs have also been

proposed (Ajzen & Fishbein, 1980; Centers of Disease Control and Prevention, 1993; Dick & Lombard, 1997; Dick, Van der Walt, Hoogendoorn, & Tobias, 1996; Glanz, Rimer, & Viswanath, 2008).

Currently, in Timor-Leste, the number of available professional counsellors is unknown. To date there appears to be very few health workers in TB services who are qualified in counselling. The MoH in Timor-Leste should encourage medical students to undertake counselling studies. Meanwhile, capacity building through adequate training on basic counselling services should be provided to the current health workers. Adequate treatment of depression will potentially enhance patients’ overall health quality, and hence improve treatment outcomes.

A public health approach to reducing stigma is to work with self-help, advocacy and support groups. According to a number of studies, access to support groups is likely to reduce the effects of stigma on patients undergoing treatment (Demissie, Getahun, & Lindtjorn, 2003; Lyon & Woodward, 2003). Support groups can enable patients to exchange information and receive mutual support, which can help improve their self-esteem (Heijnders & van der Meij, 2006).

Social support from family members, friends, and health professionals can be important for optimal treatment adherence. Social connectedness has been reported in the field of HIV/AIDS to be an influencing factor on adherence, as can help with reinforcement, reassurance or encouragement (Do, 2011). Given that TB patients are likely to interact and receive support from different groups during treatment, establishing a strong relationship is likely to be vital. Often, sick patients are cared for by their family members, community health volunteers and health care professionals, and it has been reported in a case with HIV/AIDS in other settings that such care can cause the experience of stigma (Nyblade et al., 2003). An important key aspect to be addressed is to educate those caring for patients, especially with their knowledge about the disease, and the appropriate language used to communicate to patients during

their daily interactions (Kidd & Clay, 2003). Because many TB patients reside in remote areas of the country, Kidd and Clay (2003) suggested that improved education can help empowering community members, especially patients’ family members who could benefit patients with their treatment. Thus, educating different groups of people who are involved directly in patients’ TB treatment could also directly influence the success of treatment completion.

Strong beliefs associated with traditional healers in Timor-Leste are part of the culture and their existence has been historically embedded in the community for generations. Due to the strong beliefs of the elders about traditional healers, many people can easily be influenced by such beliefs. In Timor-Leste many TB patients visit traditional healers before seeking proper treatment, and such behaviour is found to be consistent with patients in other settings (Colvin et al., 2014). Given the history and background of traditional healers, to address issues related to TB treatment and to improve overall health outcome of the population, effective interventions are required. Other societies which have encountered the same issues have proposed solutions to address such pivotal concerns. A potential solution to the problem is to blend conventional services and traditional healers in terms of supervision of TB treatment, provide possible community TB education, and engage in collaborative case findings and diagnosis (Wilkinson et al., 1999). Additionally, a study conducted in Zulu-Natal, South Africa, suggested that traditional healers are potentially an important resource to be integrated into TB control programs (Colvin, Gumede, Grimwade, Maher, & Wilkinson, 2003).

In order to achieve a better community-based TB intervention with the involvement of traditional healers, first, the MoH Timor-Leste could work more collaboratively with the local health professionals and community members to identify potential traditional healers. Second, improved training, such as general knowledge and understanding in identifying and screening individuals with TB symptoms is important. In addition, it is vital to train and monitor traditional healers to independently refer patients, conduct DOTS and assist patients with ongoing treatment (Colvin et al., 2014).

The current study found no association between adherence and social support. Also, disclosure of treatment status was not significantly associated with adherence. However, the present study found a significant interaction of these variables with psychological distress, which suggested that individuals who received adequate support were likely to have a better psychological well-being, and thus be more likely to adhere successfully to treatment. This result suggests that social support can be an important element which may not directly impact adherence, but it can reinforce, reassures and buffers the effects of variables that directly influence adherence. Hence, efforts to strengthen treatment and care, and the participation of family members and social support to maintain social connectedness may help improve treatment adherence.

CONCLUSION

Medication adherence for TB is of utmost importance in helping to cure patients, prevent further spread of the disease and avoid the development of drug resistance. Hence, identifying patients prone to non-adherence, and determining the level of adherence and its influencing factors is crucial. In doing so, it allows health carers to recognize individuals with special characteristics that should be carefully supported to maximise treatment adherence. The result of this study suggested that it is vital to ensure that assistance is given to those who struggle financially, and attention is needed to screen for sign of depression and alcohol use. Evidence also suggests that TB care and treatment services should integrate effective treatment for depression, counselling for risky behaviours, traditional healers, and the belief that chance or luck determines health outcomes. Furthermore, to empower patients, support should be given to maintain social connectedness with family and the community.

References

Abadia, E., Zhang, J., dos Vultos, T., Ritacco, V., Kremer, K., Aktas, E., . . . Sola, C. (2010). Resolving lineage assignation on Mycobacterium tuberculosis clinical isolates classified by spoligotyping with a new high-throughput 3R SNPs based

method. Infect Genet Evol, 10(7), 1066-1074. doi:

10.1016/j.meegid.2010.07.006

Adem, A., Tesfaye, M., & Mohammed, M. A. (2014). The Prevalence and Pattern of Depression in Patients with Tuberculosis on Follow up at Jimma University Specialized Hospital and Jimma Health Center. Med-Science, 3(1), 955-968. Ahmad, R. A., Mahendradhata, Y., Utarini, A., & de Vlas, S. J. (2011). Diagnostic delay

amongst tuberculosis patients in Jogjakarta Province, Indonesia is related to the quality of services in DOTS facilities. Tropical Medicine & International Health, 16(4), 412-423. doi: 10.1111/j.1365-3156.2010.02713.x

Ahmad, S. A., Wray, C. J., Rilo, H. R., Choe, K. A., Gelrud, A., Howington, J., . . . Matthews, J. B. (2006). Chronic Pancreatitis: Recent Advances and Ongoing Challenges. Current Problems in Surgery, 43(3), 135-238. doi: http://dx.doi.org/10.1067/j.cpsurg.2005.12.005

Ailinger, R. L., Black, P., Nguyen, N., & Lasus, H. (2007). Predictors of adherence to Latent Tuberculosis Infection therapy in Latino immigrants. Journal of Community Health Nursing, 24(3), 191-198.

Ailinger, R. L., Martyn, D., Lasus, H., & Lima Garcia, N. (2010). The effect of a cultural intervention on adherence to latent tuberculosis infection therapy in Latino immigrants. Public Health Nursing, 27(2), 115-120. doi: 10.1111/j.1525- 1446.2010.00834.x

Ailinger, R. L., Moore, J. B., Nguyen, N., & Lasus, H. (2006). Adherence to latent tuberculosis infection therapy among Latino immigrants. Public Health Nursing, 23(4), 307-313.

Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, N.J.: Prentice-Hall.

Allen, P., & Bennett, K. (2012). SPSS statistics: a practical guide version 20. South Melbourne, Vic: Cengage Learning Australia.

Amico, K. R., Fisher, W. A., Cornman, D. H., Shuper, P. A., Redding, C. G., Konkle- Parker, D. J., . . . Fisher, J. D. (2006). Visual analog scale of ART adherence: association with 3-day self-report and adherence barriers. J Acquir Immune Defic Syndr, 42(4), 455-459. doi: 10.1097/01.qai.0000225020.73760.c2

Amuha, M. G., Kutyabami, P., Kitutu, F. E., Odoi-Adome, R., & Kalyango, J. N. (2009). Non-adherence to anti-TB drugs among TB/HIV co-infected patients in Mbarara Hospital Uganda: Prevalence and associated factors. African Health Sciences, 9(Suppl 1), S8-S15.

Anderson, L. F., Tamne, S., Watson, J. P., Cohen, T., Mitnick, C., Brown, T., . . . Abubakar, I. (2013). Treatment outcome of multi-drug resistant tuberculosis in the United Kingdom: retrospective-prospective cohort study from 2004 to 2007. Euro Surveill, 18(40).

Aparicio, J. P., Capurro, A. F., & Castillo-Chavez, C. (2002). Markers of disease evolution: the case of tuberculosis. Journal of Theoretical Biology, 215(2), 227- 237.

Arlt, S., Lindner, R., Rösler, A., & von Renteln-Kruse, W. (2008). Adherence to Medication in Patients with Dementia: Predictors and Strategies for Improvement. Drugs & Aging, 25(12), 1033-1047.

Armijos, R. X., Weigel, M. M., Qincha, M., & Ulloa, B. (2008). The meaning and consequences of tuberculosis for an at-risk urban group in Ecuador. Significado y consecuencias de la tuberculosis para un grupo urbano de riesgo en Ecuador., 23(3), 188-197.

Aronson, J. K. (2007). Compliance, concordance, adherence. British Journal of Clinical Pharmacology, 63(4), 383-384. doi: 10.1111/j.1365-2125.2007.02893.x

Awofeso, N. (2008). Anti-tuberculosis medication side-effects constitute major factor for poor adherence to tuberculosis treatment... Garner P, Smith H, Munro S, Volmink J. Promoting adherence to tuberculosis treatment. Bull World Health Organ 2007;85:404-6. Bulletin of the World Health Organization, 86(3), B-d. Ayisi, J. G., van't, Hoog, A. H., Agaya, J. A., McHembere, W., Nyamthimba, P. O., . . .

Marston, B. J. (2011). Care seeking and attitudes towards treatment compliance by newly enrolled tuberculosis patients in the district treatment programme in

rural western Kenya: a qualitative study. BMC Public Health, 11(1), 515-524. doi: 10.1186/1471-2458-11-515

Baldwin, M. R., Yori, P. P., Ford, C., Moore, D. A. J., Gilman, R. H., Vidal, C., . . . Evans, C. A. (2004). Tuberculosis and nutrition: disease perceptions and health seeking behavior of household contacts in the Peruvian Amazon. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 8(12), 1484-1491. Baral, S. C., Karki, D. K., & Newell, J. N. (2007). Causes of stigma and discrimination

associated with tuberculosis in Nepal: a qualitative study. BMC Public Health, 7, 211-211.

Barnhoorn, F., & Adriaanse, H. (1992). In search of factors responsible for noncompliance among tuberculosis patients in Wardha District, India. Social Science & Medicine (1982), 34(3), 291-306.

Baylan, O. (2011). [Extensively drug resistant and extremely drug resistant tuberculosis forms after multi-drug resistant tuberculosis: new faces of the old disease]. Mikrobiyoloji Bülteni, 45(1), 181-195.

Behera, D. (2008). Global tuberculosis control 2008: Surveillance, planning, financing. Indian Journal of Medical Research, 128(1), 89-90.

Behera, D. (2009). Implementing the WHO stop TB strategy: A handbook for national tuberculosis control programmes. Indian Journal of Medical Research, 130(1), 95-96.

Belilovsky, E. M., Borisov, S. E., Cook, E. F., Shaykevich, S., Jakubowiak, W. M., & Kourbatova, E. V. (2010). Treatment interruptions among patients with tuberculosis in Russian TB hospitals. International Journal of Infectious Diseases, 14(8), e698-e703. doi: http://dx.doi.org/10.1016/j.ijid.2010.03.001 Bell, J., Airaksinen, M. S., Lyles, A., Chen, T. F., & Aslani, P. ( 2007). Concordance is

not synonymous with compliance or adherence. Br J Clin Pharmacol, 64(5), 710-711.

Berkwits, M., & Inui, T. S. (1998). Making use of qualitative research techniques. J Gen Intern Med, 13(3), 195-199.

Berridge, V. (2005). Making health policy: networks in research and policy after 1945. Clio Medica (Amsterdam, Netherlands), 75, 5-37.

Blackwell, B. (1979). Treatment compliance. Journal Of Medical Education, 54(5), 443-444.

Bobrik, A., Danishevski, K., Eroshina, K., & McKee, M. (2005). Prison health in Russia: the larger picture. Journal Of Public Health Policy, 26(1), 30-59.

Bock, N. N., Sterling, T. R., Hamilton, C. D., Pachucki, C., Wang, Y.-C., Conwell, D. S., . . . Vernon, A. (2002). A prospective, randomized, double-blind study of the tolerability of rifapentine 600, 900, and 1,200 mg plus isoniazid in the continuation phase of tuberculosis treatment. American Journal Of Respiratory And Critical Care Medicine, 165(11), 1526-1530.

Brannon, L., & Feist, J. (2000). Health psychology. An introduction to behaviour and health.

Brassard, P., Anderson, K. K., Menzies, D., Schwartzman, K., & Macdonald, M. E. (2008). Knowledge and perceptions of tuberculosis among a sample of urban Aboriginal people. Journal of Community Health, 33(4), 192-198.

Brimnes, N. (2007). Vikings against Tuberculosis: The International Tuberculosis Campaign in India, 1948-1951. Bulletin of the History of Medicine, 81(2), 407- 430.

Brouwer, J. A., Boeree, M. J., Kager, P., Varkevisser, C. M., & Harries, A. D. (1998). Traditional healers and pulmonary tuberculosis in Malawi. The International Journal Of Tuberculosis And Lung Disease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease, 2(3), 231-234. Brown, M. T., & Bussell, J. K. (2011). Medication Adherence: WHO Cares? Mayo

Clinic Proceedings, 86(4), 304-314. doi: 10.4065/mcp.2010.0575

Bumburidi, E., Ajeilat, S., Dadu, A., Aitmagambetova, I., Ershova, J., Fagan, R., & Favorov, M. O. (2006). Progress Toward Tuberculosis Control and Determinants of Treatment Outcomes -- Kazakhstan, 2000-2002. MMWR: Morbidity & Mortality Weekly Report, 55, 11-15.

Buskin, S. E., Gale, J. L., Weiss, N. S., & Nolan, C. M. (1994). Tuberculosis risk factors in adults in King County, Washington, 1988 through 1990. The American Journal of Public Health, 84(11), 1750-1756.

Cambanis, A., Yassin, M., Ramsay A, B., Squire, S., Arbide, I., & Cuevas, L. (2005). Rural poverty and delayed presentation to tuberculosis services in Ethiopia. Tropical Medicine & International Health, 10(4), 300-305.

Centers fo Disease Control and Prevention. (2008). Trends in tuberculosis -- United States, 2007 MMWR: Morbidity & Mortality Weekly Report (Vol. 57, pp. 281- 285).

Centers of Disease Control and Prevention. (1993). Approaches to Improving Adherence to Antituberculosis Therapy 74-75.

Chang, K. C., Leung, C. C., & Tam, C. M. (2004). Risk factors for defaulting from anti- tuberculosis treatment under directly observed treatment in Hong Kong. Int J Tuberc Lung Dis, 8(12), 1492-1498.

Chaulk, C. P., Kazandjian, V. A., & Panel, f. t. P. H. T. G. (1998). Directly Observed Therapy for Treatment Completion of Pulmonary Tuberculosis: Consensus Statement of the Public Health Tuberculosis Guidelines Panel. Journal of the American Medical Association, 279(12), 943-948.

Chiang, Y.-C., Lin, Y.-M., Lee, J.-A., Lee, C.-N., & Chen, H.-Y. (2012). Tobacco consumption is a reversible risk factor associated with reduced successful treatment outcomes of anti-tuberculosis therapy. International Journal of

Infectious Diseases, 16(2), e130-e135. doi:

http://dx.doi.org/10.1016/j.ijid.2011.10.007

Ciechanowski, P. S., Katon, W. J., & Russo, J. E. (2000). Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Archives Of Internal Medicine, 160(21), 3278-3285. doi: 10.1001/archinte.160.21.3278 Clark, P. M., Karagoz, T., Apikoglu-Rabus, S., & Izzettin, F. V. (2007). Effect of

pharmacist-led patient education on adherence to tuberculosis treatment. American Journal of Health-System Pharmacy, 64(5), 497-506. doi: 10.2146/ajhp050543

Colvin, C., Mugyabuso, J., Munuo, G., Lyimo, J., Oren, E., Mkomwa, Z., . . . Richardson, D. A. (2014). Evaluation of community-based interventions to improve TB case detection in a rural district of Tanzania. Global Health: Science and Practice, 2(2), 219-225. doi: 10.9745/ghsp-d-14-00026

Colvin, M., Gumede, L., Grimwade, K., Maher, D., & Wilkinson, D. (2003). Contribution of traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa. Int J Tuberc Lung Dis, 7(9 Suppl 1), S86-91.

Connolly, C., Davies, G. R., & Wilkinson, D. (1999). Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa. The International Journal Of Tuberculosis And Lung Disease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease, 3(12), 1081-1087.

Coreil, J., Lazardo, M., & Heurtelou, M. (2004). Cultural feasibility assessment of tuberculosis prevention among persons of Haitian origin in South Florida. J Immig Health, 6(2), 63-69.

Corless, I. B., Wantland, D., Bhengu, B., McInerney, P., Ncama, B., Nicholas, P. K., . . . Davis, S. M. (2009). HIV and tuberculosis in Durban, South Africa: adherence to two medication regimens. AIDS Care, 21(9), 1106-1113. doi: 10.1080/09540120902729932

Courtwright, A., & Turner, A. N. (2010). Tuberculosis and Stigmatization: Pathways and Interventions. Public Health Reports, 125(Suppl 4), 34-42.

Craig, G. M., Booth, H., Story, A., Hayward, A., Hall, J., Goodburn, A., & Zumla, A. (2007). The impact of social factors on tuberculosis management. Journal of Advanced Nursing, 58(5), 418-424. doi: 10.1111/j.1365-2648.2007.04257.x Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods

research. Los Angeles: SAGE Publications.

Curry, L. A., Nembhard, I. M., & Bradley, E. H. (2009). Qualitative and mixed methods provide unique contributions to outcomes research. Circulation, 119(10), 1442- 1452. doi: 10.1161/circulationaha.107.742775

Daniel, W. W. (2009). Biostatistics: a foundation for analysis in the health sciences. Hoboken, N.J: John Wiley & Sons.

Demissie, M., Getahun, H., & Lindtjorn, B. (2003). Community tuberculosis care through “TB clubs” in rural North Ethiopia. Social Sci Med, 56, 2009-2018. Demissie, M., & Kebede, D. (1994). Defaulting from tuberculosis treatment at the

Addis Abeba Tuberculosis Centre and factors associated with it. Ethiop Med J, 32(2), 97-106.

Dick, J., Jaramillo, E., Maher, D., & Volmink, J. (2003). World Health Organisation: Adherence to long-term therapies: Evidence for action. Retrieved from: http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf Dick, J., & Lombard, C. (1997). Shared vision--a health education project designed to

enhance adherence to anti-tuberculosis treatment. Int J Tuberc Lung Dis, 1(2), 181-186.

Dick, J., Van der Walt, H., Hoogendoorn, L., & Tobias, B. (1996). Development of a health education booklet to enhance adherence to tuberculosis treatment. Tuber Lung Dis, 77(2), 173-177.

Do, H. M. (2011). Antiretroviral therapy (ART) adherence among people living with HIV/AIDS (PLHIV) in the north of Vietnam : a multi-method approach

Do, H. M., Dunne, M. P., Kato, M., Pham, C. V., & Nguyen, K. V. (2013). Factors associated with suboptimal adherence to antiretroviral therapy in Viet Nam: a cross-sectional study using audio computer-assisted self-interview (ACASI). BMC Infectious Diseases, 13(1).

Dodge, J. A., & Clark, N. M. (1999). Exploring self-efficacy as a predictor of disease management. Health Education & Behaviour. 26(72-89).

Dodor, E. A., & Kelly, S. J. (2010). Manifestations of tuberculosis stigma within the healthcare system: The case of Sekondi-Takoradi Metropolitan district in Ghana.

Health Policy, 98(2–3), 195-202. doi:

http://dx.doi.org/10.1016/j.healthpol.2010.06.017

Dodor, E. A., Neal, K., & Kelly, S. (2008). An exploration of the causes of tuberculosis stigma in an urban district in Ghana. The International Journal Of Tuberculosis And Lung Disease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease, 12(9), 1048-1054.

Eastwood, S. V., & Hill, P. C. (2004). A gender-focused qualitative study of barriers to accessing tuberculosis treatment in The Gambia, West Africa. The International Journal Of Tuberculosis And Lung Disease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease, 8(1), 70-75. Elliott RA, M. J. ( 2009). Standardised assessment of patients' capacity to manage

medications: a systematic review of published instruments. BMC Geriatr, 9(27). Eticha, T., & EKassa, E. (2014). Non-Adherence to Anti-TB Drugs and Its Predictors among TB/HIV Co- Infected Patients in Mekelle, Ethiopia. Journal of Bioanalysis & Biomedicine.

Farmer, P., Robin, S., Ramilus, S., & Kim, J. (1991). Tuberculosis, poverty, and “compliance”: lessons from rural Haiti. Semin Respir Infect, 6(4), 254-260. Figueroa-Munoz, J., Palmer, K., Poz, M., Blanc, L., Bergström, K., & Raviglione, M.

(2005). The health workforce crisis in TB control: a report from high-burden countries. Human Resources for Health, 3(1), 2.

Finnie, R. K. C., Khoza, L. B., van den Borne, B., Mabunda, T., Abotchie, P., & Mullen, P. D. (2011). Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high

burdens of TB and HIV. Tropical Medicine & International Health, 16(4), 394- 411. doi: 10.1111/j.1365-3156.2010.02718.x

Fourie, B. (2001). The burden of tuberculosis in South Africa. Tygerberg Medical