https://doi.org/10.36570/jduhs.2023.3.

1905
JDUHS

ORIGINAL ARTICLE
Psychological Distress in Adult Pulmonary Tuberculosis Sufferers: A
Community-Based Survey 1 1 2
Suarnianti Suarnianti, Yusran Haskas, Indah Lestari
1. Department of Nursing, Nani Hasanuddin Health Institute, Makassar, 90245, Indonesia.
2. Department of Nursing, Bina Sehat PPNI University, Mojokerto, 61364, Indonesia.
Correspondence to: Suarnianti Suarnianti, Email: suarnianti@stikesnh.ac.id, ORCID: 0000-0003-0893-6313
ABSTRACT
Objective: This study aims to assess the prevalence and emotional symptoms of psychological distress in
pulmonary tuberculosis (TB) sufferers.
Methods: This cross-sectional study was conducted at six primary health centers in Makassar City, Indonesia
from June to November 2022. TB patients were diagnosed using national TB program guidelines. The study
included patients 18-60 years old, did not have psychosis or communication difficulties, had no difficulty
understanding the questionnaire's contents and were capable to following the study protocols. Self-designed
questionnaires were used to obtain data on sociodemographic characteristics and medical conditions. The
outcome of the study was psychological distress among individuals with pulmonary TB, which was measured
using the Kessler Psychological Distress Scale (K10).
Results: Of total 308 TB patients, the mean age was 40.88 ± 16.09 years. Psychological distress was observed in
239 (77.6%) patients. The median psychological distress was found significantly higher in patients with older age
(p-value 0.041), senior high school (p-value 0.046), unemployed (p-value <0.001), had a monthly income below
the regional minimum wage (p-value 0.015), smokers (p-value 0.049), and had abnormal blood pressure (p-value
<0.001). Moreover, it was observed that tiredness (2.44 ± 0.06), fidgety (2.98 ± 0.06), sadness (2.04 ± 0.06), and
hopelessness (2.02 ± 0.05) were prominent symptoms experienced by TB patients due to psychological distress.
Conclusion: More than three-fourths of TB patients experienced psychological distress. Smoking and abnormal
blood pressure, along with specific demographic factors, significantly influenced distress levels. Prominent
emotional symptoms in distressed patients included fatigue, restlessness, sadness, and hopelessness.
Keywords: Emotional Distress, Psychological Distress, Pulmonary Tuberculosis.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creative commons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION without TB.3 Psychological distress is described as an

unpleasant subjective state of depression and anxiety.
Indonesia is a low and middle-income country with the Moreover, psychological distress results in emotional
third highest prevalence of pulmonary tuberculosis and physiological manifestations that interfere with
(TB), after India and China. It is reported that in daily life activities characterized by depression, anxiety,
Indonesia, there are 824,000 TB new cases and 93,000 and somatic symptoms. Psychological distress can lead
deaths per year; this number of deaths is equal to 11 to a poor perception of the environment, oneself, and
4
deaths per hour. In Indonesia, the productive age others.
group, particularly those aged 45 to 54 years, has the Mental problems are often neglected; thus, these
largest number of TB cases.1 In 2019, it is estimated that problems must get attention in TB treatment because
10 million people were infected with TB, and 1.41 million mental health affects a patient's adaptation to the
5
people died from the disease worldwide; these disease. Several studies investigated common mental
2
numbers are nearly similar to those in 2018. disorders in TB patients in low and middle-income
Psychological distress is more prevalent in TB patients countries and have discovered high rates of general
in developing countries; people with TB infection are mental disorders as follows: Pakistan for 46.3%-80%,6
7 8 9
more subject to psychological pressure than those Nigeria for 27.7%-30%, Ethiopia for 64 %, India for 76%,
J Dow Univ Health Sci 2023, Vol. 17 (3): 121-127 121
Suarnianti et al. Psychological Distress in Adult Pulmonary TB Patients
10 13
and South Africa for 46 %. More than 80% of the disease Scale (K10). This scale consisted of 10 items. Emotional
11
burden occurs in low- and middle-income countries. disorders as a manifestation of psychological distress
In addition, such an issue is still frequently neglected in manifest in a variety of symptoms include sad, tired,
Indonesia. It is pivotal to obtain accurate data on the nervous, hopeless, fidgety, effortless, depressed,
prevalence and predictors of psychological distress worthless. They reported their distress over the past 30
problems in pulmonary TB patients in Indonesia whose days using a five-point Likert scale ranging from 1 =
society is multicultural. Based on the aforementioned never to 5 = all of the time. An item score of 10-19
explanation, this study aims to identify the prevalence indicates likely to be well; 20-24 indicates likely to have a
and emotional symptoms of psychological distress in mild disorder; 25-29 indicates likely to have a moderate
pulmonary TB patients in eastern Indonesia. disorder; 30-50 indicates likely to have a severe
disorder.13Instrument was translated into Indonesian by
METHODS Sitompul. The reliability and validity of the translated
version were also verified. Overall Cronbach's alpha
This cross-sectional study was conducted at six primary coefficient of the scale is 0.931, and the content validity
health centers (PHC) in Makassar City, South Sulawesi is 0.834.14
Province, Indonesia from June to November 2022. Statistical Package for Social Sciences (SPSS) version 24
South Sulawesi Province is one of the regions in the was used for the purpose of statistical analysis. The
eastern part of Indonesia, which ranks seven with the mean ± SD was calculated for age, and the median
highest prevalence of TB in Indonesia. Six PHCs were interquartile range (IQR) was computed for the
selected because the highest number of TB patients psychological distress score. Frequencies and
was found there. The Ethics Committee of Nani percentages were calculated for gender, education,
Hasanuddin Health Institute approved this study occupation, Income, smoking, BMI, upper arm
number (0395b/STIKES-NH/KEPK/V/2022). All circumference, blood pressure, and emotional
participants provided informed consent, participated disorders. Normality of the data was checked by
voluntarily, and signed a consent form. Shapiro-Wilk test. The data were not normally
The inclusion criteria were TB patients diagnosed using distributed, therefore non-parametric tests were
national TB program guidelines, were 18-60 years old, applied. Inferential statistics were explored using
did not have psychosis or communication difficulties, Mann-Whitney U test and Kruskal-Wallis test to
had no difficulty understanding the questionnaire's compare psychological distress scores with
contents, and could comply with study protocols. The demographic and clinical characteristics of TB patients.
exclusion criteria were patients who had completed The p-value of ≤0.05 was considered as significant.
their treatment. Initially, the estimated sample size of
240 was calculated using Open Epi taking 50% RESULTS
12
proportion of the condition. However, to adjust for
non-response and incomplete data, 312 TB patients This study was completed on 308 TB patients with a
were included. Later on, four questionnaires were mean age of 40.88 ± 16.09 years. There were 161 (52.3%)
removed due to a considerable amount of missing females and 147 (47.7%) males. Nearly one-third of the
information. Therefore, 308 patients' data were finally participants had an elementary school education 56
included in the study. (18.2%) or a lower level of education 59 (19.2%). The
At baseline, demographic items assessed participants' majority of the patients were unemployed and had
characteristics, including age, sex, education, monthly income below the regional minimum wage i.e.,
occupation, income, smoking behavior, body mass 159 (51.6%) and 265 (86.0%). Most of the patients were
index (BMI) (skinny: 17.0-18.4, normal: 18.5-22.9, non-smokers 167 (54.2%), had normal blood pressure
overweight: 23.0-24.9, obesity: ≥ 25.0), upper arm 160 (51.9%), had normal BMI 157 (51.0%), and had
circumference (underweight: < 90%, normal: 90-100%, underweight upper arm circumference 216 (70.1%).
overweight: 110-120%), and blood pressure. Self- Psychological distress was observed in 239 (77.6%)
designed questionnaires were used to obtain data on patients. Among them 116 (37.7%) had mild distress, 74
sociodemographic characteristics and medical (24.0%) had moderate distress and 49 (15.9%) had
conditions. severe distress. The median psychological distress was
The outcome of the study was psychological distress found significantly higher in older age (p-value 0.041)
among individuals with pulmonary TB, which was patients, those studied senior high school (p-value
measured using the Kessler Psychological Distress 0.046), were unemployed (p-value <0.001), had a
122 J Dow Univ Health Sci 2023, Vol. 17 (3): 121-127
Suarnianti et al. Psychological Distress in Adult Pulmonary TB Patients
monthly income below the regional minimum wage (p- follows tiredness (2.44 ± 0.06), fidgety (2.98 ± 0.06),
value 0.015), smokers (p-value 0.049), and had sadness (2.04 ± 0.06), and hopeless (2.02 ± 0.05).
abnormal blood pressure (p-value <0.001) (Table 1 & 2). Moreover, tiredness fidgety, sadness, and
TB patients experience various symptoms of emotional hopelessness consistently experiencing in 45 (14.6%), 29
disorders. The mean of the most prominent items are as (9.4%), 9 (2.9%), and 21 (6.8%) patients respectively (Table 3).

Table 1: Comparison of psychological distress scores with demographic characteristics of TB Patients (n=308)
Psychological Distress Scores
Variables Total p-value
Median (IQR)
Age (years)
25-34 22 24 (21-30)
0.041~*
35-44 230 22 (19-27)
45-60 56 26 (21-29)
Gender
Male 147 23 (20-28) 0.068^
Female 161 22 (19-27)
Education
Not Attending Schools 44 21.5 (18.5-26.5)
Elementary Schools 56 24 (20-28.5)
0.046~*
Junior High Schools 59 21 (18.5-28)
Senior High Schools 100 24.5 (20.5 – 28)
Higher Education 49 20 (18-26)
Occupation
Working 149 21 (18-26) <0.001^*
Unemployed 159 24 (21-29)
Income
≤ Regional Minimum Wage 265 23 (20-28) 0.015^*
> Regional Minimum Wage 43 20 (18-25)
-TB: Tuberculosis, IQR: Inter quartile range, Regional minimum wage: 3,385,145 Indonesian Rupiah (IDR)
^
Mann-Whitney U test applied, ~Kruskal-Wallis test applied, *p-value ≤ 0.05

Table 2: Comparison of psychological distress scores with clinical characteristics of TB Patients (n= 308)
Psychological Distress
Clinical characteristics Total p-value
Scores Median (IQR)
Smoking
Yes 141 22 (19-26) 0.049^*
No 167 21 (18-26)
Body Mass Index (kg/m2)
Skinny 124 21 (19-26)
Normal 157 24 (19-29) 0.156~
Overweight 24 24 (19.5-27)
Obesity 3 26 (24-27)
Upper Arm Circumference
Underweight 216 22 (19-28)
0.380~
Normal 80 21 (19-27)
Overweight 12 26.5 (13-29)
Blood Pressure
Normal 160 21 (18-27) <0.001 ^*
Abnormal 148 25 (21-28.5)
-TB: Tuberculosis, IQR: Inter quartile range
^
Mann-Whitney U test applied, ~Kruskal-Wallis test applied, *p-value ≤ 0.05
J Dow Univ Health Sci 2023, Vol. 17 (3): 121-127 123
Suarnianti et al. Psychological Distress in Adult Pulmonary TB Patients
Table 3: Emotional disorders as a manifestation of psychological distress in TB Patients
Emotional Disorders n (%) Item Average Scores
Tired
Never 32 (10.4)
Seldom 49 (15.9)
2.44 ± 0.06
Sometimes 93 (30.2)
Often 89 (28.9)
Always 45 (14.6)
Nervous
Never 78 (25.3)
Seldom 94 (30.5)
1.79 ± 0.06
Sometimes 69 (22.4)
Often 43 (14.0)
Always 24 (7.8)
Hopeless
Never 89 (28.9)
Rarely 80 (26.0
2.02 ± 0.05
Sometimes 58 (18.8)
Often 60 (19.5)
Always 21 (6.8)
Fidgety
Never 136 (44.2)
Rarely 72 (23.4)
2.98 ± 0.06
Sometimes 49 (15.9)
Often 22 (7.1)
Always 29 (9.4)
Depressed
Never 167 (54.2)
Rarely 67 (21.8)
1.92 ± 0.05
Sometimes 41 (13.3)
Often 24 (7.8)
Always 9 (2.9)
Effortless
Never 65 (21.1)
Rarely 51 (16.6)
1.86 ± 0.05
Sometimes 32 (10.4)
Often 80 (26.0)
Always 80 (26.0)
Sad
Never 145 (47.1)
Rarely 88 (28.6)
2.04 ± 0.06
Sometimes 45 (14.6)
Often 21 (6.8)
Always 9 (2.9)
Worthless
Never 176 (57.1)
Rarely 80 (26.0)
1.80 ± 0.05
Sometimes 33 (10.7)
Often 9 (2.9)
Always 10 (3.2)
-TB: Tuberculosis
124 J Dow Univ Health Sci 2023, Vol. 17 (3): 121-127
Suarnianti et al. Psychological Distress in Adult Pulmonary TB Patients

DISCUSSION lead to psychological distress. In addition, another

study has found that patients with lower levels of
TB remains a significant public health concern, particul- health literacy experience more psychological
24
arly in low-income communities like the one in our distress. A low education level has become a barrier for
study. This community-based survey aimed to assess TB patients because they have limited or no ability to
psychological distress in adult pulmonary TB sufferers search for health information and only receive
within the Pakistani population, shedding light on information from their care providers; consequently,
various socio-demographic factors and associated health literacy declines.
symptoms of emotional distress. This study has discovered that the high economic
The findings of this study revealed that a substantial burden of TB treatment contributes to higher degrees
portion of the TB patients experienced psychological of psychological distress in TB patients. Patients with a
distress, with seventy eight percent of participants high economic burden are more likely to have low
reporting symptoms of distress. This high prevalence of incomes and come from low-income families, both are
25
psychological distress among TB patients is consistent factors of psychological distress. Furthermore, the
with findings from previous studies conducted in India,15 increased economic burden complicates patients
16 3 17
East China, Ethiopia, and South Africa. The difference paying for higher drug costs and examination costs in
in prevalence is probably caused by background, the long run. Such conditions will cause significant
25
culture, social aspects, economy, and patient psychological stress. A previous study also showed
population. The condition of TB patients is worsened by that about fifty percent of the patients fail to return to
26
the COVID-19 pandemic, which causes delays in patient work effectively even a year following treatment.
care, diagnosis, and clinical conditions. Inability to work normally can hamper their income,
The current study revealed that TB patients experien- burden the economic conditions of poor families, and
ced psychological distress. The distress causes various trigger the patients as a burden to their families. Such
symptoms, such as anxiety, sadness, despair, and conditions cause psychological stress. Providing
depression. The emergence of psychological distress financial support to patients can minimize levels of
can result in a number of undesirable effects, including psychological distress as well as improve treatment
poor treatment results,18 increased morbidity and adherence, quality of life, and treatment results.17
19
death, and increased medication resistance risk. The study also investigated the specific symptoms of
However, proper interventions can minimize emotional distress experienced by TB patients.
20
psychological distress. As a result, it is critical to Notably, symptoms such as tiredness, fidgetiness,
investigate effective intervention options to address sadness, and hopelessness were frequently reported.
this issue. These symptoms may reflect the psychological burden
On demographic factors, the median psychological of living with a chronic illness and the social stigma
distress was found significantly higher in older age often attached to TB, both of which can affect a
patients. This finding is consistent with a study in patient's emotional well-being.
3
Ethiopia. Another study found that older age This study provides substantial proof of an increased
correlates with psychological distress. This could proportion of psychological distress among adult
happen because older TB patients are a vulnerable pulmonary TB sufferers. However, it has certain
group with greater health issues, a high death rate, and limitations. One limitation of this study is its cross-
are more likely to experience severe medication sectional design, which limits our ability to establish
reactions.21 causality. Second, the study was conducted in a specific
In addition, this current study has discovered that a geographic area, potentially limiting the generaliza-
patient with a higher education level can experience bility of the findings to broader populations of TB
greater psychological distress. A previous study asserts sufferers. Based on these limitations, further research is
that education is a risk factor for depression.22 However, recommended to employ more accurate sampling
this finding disagrees with a previous study stating that methods (randomization) to prevent the risk of
general mental disorders are more common in healthy selection bias and investigate innovative therapies for
23
persons with lower levels of education. Patients with TB patients' psychological distress.
lower levels of education might not understand TB
correctly, often experience confusion about whether CONCLUSION
TB is curable, and are emotionally disturbed after being
diagnosed with the disease. Such conditions can easily This study concludes that more than three-fourths TB
J Dow Univ Health Sci 2023, Vol. 17 (3): 121-127 125
Suarnianti et al. Psychological Distress in Adult Pulmonary TB Patients
patients were found with psychological distress. Med Prim Care 2020; 9:4174–80.
Factors such as older age, lower education levels, doi:org/10.4103/jfmpc.jfmpc_1404_20
unemployment, inadequate income, smoking, and 6. Zavala GA, Haidar-Chowdhury A, Prasad-Muliyala K,
abnormal blood pressure were associated with median Appuhamy K, Aslam F, Huque R, et al. Prevalence of
physical health conditions and health risk behaviours in
psychological distress scores. Prominent emotional
people with severe mental illness in South Asia: multi-
symptoms among distressed TB patients included
country cross-sectional survey. BJPsych Open 2023;
tiredness, fidgetiness, sadness, and hopelessness. 9:e43. doi:10.1192/bjo.2023.12
Addressing the psychological well-being of pulmonary 7. Agberotimi SF, Akinsola OS, Oguntayo R, Olaseni AO.
TB sufferers is crucial alongside their physical health. Interactions between socioeconomic status and mental
health outcomes in the Nigerian context amid COVID-19
ETHICAL APPROVAL: This study was approved by the pandemic: a comparative study. Front Psychol 2020;
Ethics Committee of Nani Hasanuddin Health Institute 11:559819.
(Ref. No.0395b/STIKES-NH/KEPK/V/2022). doi:10.3389/fpsyg.2020.559819
8. Hasan SI, Yee A, Rinaldi A, Azham AA, Mohd Hairi F, Amer
AUTHORS' CONTRIBUTION: SS: Contributed to the Nordin AS. Prevalence of common mental health issues
study design, data interpretation and review of the final among migrant workers: A systematic review and meta-
manuscript. YH & IL: Jointly proposed the study, analysis. PLoS One 2021; 16:e0260221.
analysed the data and prepared the final draft. doi:10.1371/journal.pone.0260221
All authors approved the final version of the 9. Chatterjee K, Chauhan VS. Epidemics, quarantine and
manuscript. mental health. Med J Armed Forces India 2020; 76:125-7.
doi:10.1016/j.mjafi.2020.03.017
CONFLICT OF INTEREST: The authors declare no 10. Docrat S, Besada D, Cleary S, Daviaud E, Lund C. Mental
conflict of interest. health system costs, resources and constraints in South
Africa: a national survey. Health Policy Plan 2019;
FUNDING: The author(s) received no financial support 34:706–19. doi:10.1093/heapol/czz085
for the research, authorship, and/or publication of this 11. World Health Organization. Depression and other
article. common mental disorders: global health estimates.
World Health Organization; 2017; Available from
Received: July 20, 2023 https://www.who.int/publications/i/item/depression-
Accepted: November 03, 2023 global-health-estimates
12. Sullivan KM, Dean A, Soe MM. OpenEpi: a web-based
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