Thesis (MPhil (Communicable Diseases)) (Dept of Interdisciplinary Health Sciences. Community Health))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: Global control of the tuberculosis (TB) epidemic remains one of the greatest health challenges of the 21st century, despite the availability of effective treatment over the past 50 years. The rising incidence of transmitted (primary) drug resistant TB threatens the very fabric of conventional TB control efforts, which are already strained by a rampant human immunodeficiency virus (HIV) epidemic. Ongoing transmission of Mycobacterium tuberculosis is a key factor that sustains the TB epidemic in endemic areas such as the socio-economically deprived townships of Cape Town, South Africa. My research explores the disease context, or social terrain, of TB in this endemic setting. It is primarily concerned with how the social terrain of endemic TB may contribute to ongoing transmission and the potential that it holds for enhancing TB control efforts. Analyses of qualitative data from eight township research sites in and around Cape Town show that pragmatic and novel approaches are required to pierce through the enormity of TB as a political and economic problem. Broadening the current biomedical focus on treating individual patients, to include more holistic community-based interventions, can and should be developed. Data were collected as part of qualitative pre-intervention community surveys conducted in 2005 and 2006 for a public health intervention trial (ZAMSTAR) performed in Zambia and South Africa. Twenty-four communities were selected as research sites and this study draws on the survey data collected in the trial’s eight South African sites. Although the data were collected for the ZAMSTAR trial, the aims and analyses presented in this study - which seek to improve our understanding of how the social terrain is meaningful for TB control - remain independent of ZAMSTAR. Through a retrospective analysis of the South African data, I inductively present three distinctive ways in which the social terrain is meaningful for TB control. First, the interaction between social cohesion and social diversity may be an important variable that predicts community response to public health interventions aimed at reducing the prevalence of TB in these endemic areas. This is demonstrated by triangulating ZAMSTAR’S adaptation of a social systems model with further analysis of the research sites. Second, the study identifies a common discourse running through the sites that stigmatizes TB as both a dirty and HIV-related disease. It is argued that this may be significantly contributing to TB diagnostic delay and I call for more holistic approaches to TB control that can reduce perceived marginalization and TB-HIV stigma. Third, congregate settings emerge as noteworthy visible features of social terrain that clearly have the potential to facilitate TB transmission within communities. The pre-intervention surveys qualitatively described public spaces within each research site and the use thereof. Basic principles of TB transmission are applied to these descriptions, developing a novel method of mapping the relative transmission risk possibly posed. Innovative use of similar approaches could identify likely transmission “hot spots” that may serve as focal points for targeted interventions, such as adjustments that increase ventilation or encourage TB suspects to seek urgent medical diagnosis and treatment. / AFRIKAANSE OPSOMMING: Die beheer van tuberkulose (TB) bly steeds een van die grootste gesondheids uitdagings van die 21ste eeu, ten spyte van die beskikbaarheid van effektiewe behandeling vir die afgelope 50 jaar. Die stygende insidensie van oorgedraagde (primêre) middelweerstandige TB bedreig die wese van konvensionele TB kontrole programme, wat reeds gebuk gaan onder die oorweldigende impak van die menslike immuungebrek virus (MIV) epidemie. Ononderbroke oordrag van Mycobacterium tuberculosis is ‘n kardinale faktor wat die epidemie onderhou in areas soos die sosioekonomies agtergeblewe dele van Kaapstad, Suid-Afrika. My navorsing ondersoek sosiale terrein (konteks) van TB in hierdie hiperendemiese konteks. Dit is primêr gemoeid met die moontlike bydrae van die sosiale terrein tot voortgaande TB oordrag en die potensiaal wat dit mag inhou om TB kontrole te verbeter. Analise van kwalitatiewe data van agt agtergeblewe gemeenskappe in en om Kaapstad wys dat nuwe en pragmatiese benaderings benodig word om die volle omvang van TB as ‘n politieke en ekonomiese problem aan te spreek. Data is versamel as deel van kwalitatiewe pre-intervensie gemeenskapsopnames wat gedoen is gedurende 2005 en 2006 vir ‘n publieke gesondheid intervensie studie (ZAMSTAR) in Zambië en Suid-Afrika. Die studie sou poog om die TB prevalensie betekenisvol te verlaag in gemeenskappe wat erg geaffekteer word deur MIV. Vir navorsings doeleindes is vier-en-twintig gemeenskappe geselekteer, waaronder agt Suid-Afrikaanse gemeenskappe. My studie analiseer kwalitatiewe data wat versamel is in hierdie agt gemeenskappe, wat verskeie observasie en deelnemende tegnieke ingespan het. Die studie poog om algemene begrip te verbeter van hoe die sosiale terrein betekenisvol kan wees in TB kontrole; dit is my eie werk en is totaal onafhanklik van die groter ZAMSTAR studie. Induktiewe retrospektiewe analise van data identifiseer drie voorbeelde wat illustreer hoe die sosiale terrein betekenisvol mag wees vir TB kontrole. Eerstens, die interaksie tusses sosiale kohesie en sosiale diversiteit mag ‘n belangrike verandelike wees wat gemeenskapsrespons tot publieke gesondheidsintervensies voorspel. Dit word geïllustreer deur die toepassing van ‘n sosiale sisteme model (soos aangepas deur ZAMSTAR) en analise van ander aanvullende data. Tweedens, identifiseer die studie ‘n gemeenskaplike diskoers in alle navorsings gemeenskappe wat TB stigmatiseer as beide ‘n vuil en MIV-verwante siekte. Dit word geargumenteer dat hierdie verskynsel moontlik betekenisvol bydra tot vertraging van TB diagnose en die nodigheid vir meer holistiese benaderings wat marginalisasie en TB-HIV stigma kan verminder word uitgewys. Derdens blyk dit dat openbare vergaderplekke ‘n belangrike deel van die sosiale terrein vorm en duidelik die potensiaal het om TB oordrag binne gemeenskappe te fasiliteer. Die pre-intervensie opnames het alle openbare vergaderplekke sorgvuldig beskryf en basiese beginsels van TB oordrag is gebruik om vergaderplekke geografies te kaart volgens die moontlike transmissie risiko wat dit mag inhou. Innoverende gebruik van GIS-gebasseerde benaderings, soortgelyk aan die metode wat gebruik is om potensiële “transmission hot spots” te kaart, mag bydra om intervensies beter te fokus, deur bv. verbeterde ventilasie te verskaf of mense met simptome van TB aan te moedig om dringend mediese hulp te soek.