Tuberculosis (TB) is a contagious, airborne, bacterial infection caused by Mycobacterium tuberculosis (World Health Organization [WHO], 2023a). Due to the infectious and airborne properties of TB, about one-fourth of the worlds population has been infected with TB (Houben, 2016). TB affects the lungs and other extrapulmonary tissues such as bones, lymph nodes, meninges, liver, adrenal glands, and spleen (Le, 2017; Saikat et al., 2020), but then TB is preventable and curable (WHO, 2023a). Closely related to TB is cystic fibrosis which is a genetic disease affecting mainly the lungs (Ikwuka, 2023a). Other organs which can be affected by cystic fibrosis include the pancreas, liver, kidneys, and intestine. Cystic fibrosis is caused by mutations in both copies of the gene for cystic fibrosis trans-membrane conductance regulator (CFTR) protein and has autosomal recessive mode of inheritance (Ikwuka, 2023a). Clinical features of cystic fibrosis include dyspnea, cough with sputum, sinusitis, poor growth, fatty stool, fingers and toes clubbing, etc (Saikat et al., 2020; Ikwuka, 2023a).

TB was reported by WHO as the second leading cause of death (1.3 million deaths) from a single infectious agent in 2022 after coronavirus disease (COVID-19) and caused almost twice the number of deathslinked to HIV/AIDS (WHO, 2023a). The annually reported new cases per 100,000 population have increased by 3.9% from 128 (95% UI: 120-137) in 2020 to 133 (95% UI: 124-143) in 2022, after an approximately annual 2% decline between 2010 and 2020 (Emery, 2021). Nigeria is shortlisted among the 30 countries with high TB burden. With a total of 467,000 cases reported in 2021 (WHO, 2023b), Lagos State accounted for about 11%(51,370) of the total TB cases (Adebowale-Tambe, 2022). TB complications are compounded by HIV/AIDS, the multi-drug resistant (MDR) tuber-culosis variant, and depression (WHO, 2023a). Chronic metabolic disorders have the capacity to compromise immunity due to the activation of different systemic, immune inflammatory processes. Metabolic disorders e.g. Hypertension, Adiposity, Diabetes mellitus and Dyslipidemia collectively known as Metabolic Syndrome Diseases (MSDs) are diseases related to one another and have very high morbidity and mortality rates (Ikwuka, 2015; Ikwuka, 2017a; Ikwuka, 2017c; Ikwuka, 2023c; Ikwuka, 2023f; Virstyuk, 2016). Results obtained from different researches have shown that hypertension, diabetes mellitus, adiposity and dyslipidemia, asymptomatic hyperuricemia, activation of systemic immune infla-mmation and fibrogenesis (which is also noticeable in chronic TB), can lead to kidney damage (Ikwuka, 2017d; Ikwuka, 2017e; Ikwuka, 2018a; Ikwuka, 2018c; Ikwuka, 2018d; Ikwuka, 2019a; Ikwuka, 2019c; Ikwuka, 2022; Ikwuka, 2023d; Virstyuk, 2017a; Virstyuk, 2018a; Virstyuk, 2019; Virstyuk, 2021a; Virstyuk, 2021b). Kidney damage can lead to anemia due to decreased secretion of erythropoietin. Hemoptysis (blood in sputum) is one of the symptoms of chronic TB and is associated with oxidative stress. Linked with the induction of oxidative stress are major free radicals. Among these major free radicals, superoxide anion, hydroxyl radical, and hydroperoxyl radical are of physiological significance. Non-radical of physiological significance is hydrogen peroxide (Ikwuka, 2023b, Ekechi, 2023a). Hemoptysis can also lead to anemia (Inya, 2023a; Inya, 2023b). Patients with Vitamin K deficiency are also prone to different degrees of bleeding which can lead to anemia (Ikwuka, 2023e). Depression is a common mental disorder. It is characterized by sadness, loss of interest in things that once interested the individual, feelings of hopelessness or dejection, troubled concentration, or thoughts of being better off dead or hurting oneself (Kroenke, 2002). Depression and anxietyhave an average lifetime prevalence of 12%, and both are the highest cause of mental disorders (Bains, 2023). A single experience of depression increases the probability of becoming depressed again, and continues subsequently (National Institute of Mental Health [NIMH], 2021; Institute of Health Metrics and Evaluation, 2022).

Women suffer depression almost as twice as men, due tothe effects of childbirth, hormonal differences, psy-chosocial stressors in men and women, and the behavioral model of learned helplessness (Pederson, 2014). The presence of disease increases the chances of depression in a person. A typical proof was in 2020 when COVID-19 emerged, the number of people with depression increased by 28% from the 280 million reported the previous year (WHO, 2022). Depression is common among TB patients with a prevalence of 45.5% (Ige, 2011), particularly among TB patients with extensive pathology of the disease, the elderly, chronic TB infection, and low socio-economic status. A systematic review of the prevalence of depression among TB patients also found that the coexistence of depression and tuberculosis increases the risk of comorbidity (Duko, 2020). Adherence to a treatment plan is essential for quick recovery. However, poor compliance with treatment plans for chronic TB infection has been associated with mental disorders like depression (DeJean, 2013). Early diagnosis and treatment of depression in TB patients may there-forehelp to ensure compliance to treatment. Neverthe-less, there is also need for new and effective treatment options in patients with Metabolic Syndrome Diseases. Sodium-Glucose Linked Transporter 2 (SGLT-2) inhibitors e.g. Dapagliflozin and Glucagon-like Pep-tide 1 Receptor Agonists (GLP-1 RAs) e.g. Liraglutide have been found to improve the efficacy of treatment and clinical course of type 2 diabetes mellitus and hypertension in patients with such comorbidities (Ikwuka, 2017b; Ikwuka, 2018b; Ikwuka, 2019b; Ikwuka, 2021; Virstyuk, 2017b; Virstyuk, 2018b; Virstyuk, 2018c). It has also been documented that coconut water has hepatorenal protective functions in alloxan-induced type 1 diabetes mellitus (Ekechi, 2023b). The control and management of TB face huge challenges both locally and internationally. These challenges include poor policy implementation, health-care facilities delaying the delivery of tuberculosis supplies, medical personnels poor adherence to guide-lines, and very importantly, patients poor compliance with treatment routine. In addition, with the paucity of information on the knowledge and attitude of tuber-culosis patients and factors associated with depression in TB patients; this study, therefore, assesses the knowledge, attitude and factors associated with depre-ssion in TB patients attending DOTS centers in Lagos State, South-West Nigeria. 

Study Setting

Thiscross-sectional, descriptive study was conducted in 8 out of the 78DOTS centers in Lagos State, South-West Nigeria. Of these DOTS centers, 3 are tertiary, 24 are secondary, 31 are primary, and 20 are private centers.

Study Population and Sample Size Determination

The study population consists of TB patients attending DOTS centers for treatment. With 51,370 reported cases of tuberculosis infection in Lagos State, Kish Leslies formulafor cross-sectional studies were dep-loyed in determining the sample size (Okeke, 2023a; Okeke, 2023b; Udeh, 2023).

n=(Z^2 PQ)/d^2 

Where,

n = minimum sample size required with a study population >10,000

Z = standard normal deviate at 95% confidence level = 1.96

P = incidence rate from a previous study =27.7% (0.277) (Baba, 2009)

Q = complementary proportion = 1-P = 0.723

d = degree of accuracy desired = 5.0% (0.05)

Therefore: 

n_= (〖1.96〗^2×0.277×0.723)/〖0.05〗^2 =0.7694/0.0025= 307.74 ≈308

A minimum sample size of 308 was calculated, and with the addition of 10% non-response rate, the sample size required increased to 342.

Study Procedure

This study spanned from March 2023 to June 2023. Eight DOTS centers were randomly selected using a table of random numbers from the 78 DOTS centers. These centers were in two tertiary, four secondary, and two primary health facilities. The centers in the primary health facilities were visited just once. TB patients in the outpatient departments, 18 years old or older, and voluntarily consented to the study were included in this study. TB patients below 18 years of age, TB patients who did not voluntarily consent, and TB in-patients (TB patients on admission) were excluded from this study. Data collection was done by the research team after being trained on the research procedure. Patient Health Questionnaire-9 (PHQ-9) was used to determine depression among the parti-cipants. Structured pre-tested questionnaireswere used for data collection. The questionnaire had sections for socio-demographic parameters, the participants know-ledge of depression, the participants attitude towards depression, and factors associated with depression among the participants (respondents) were used.

Data Analysis

Statistical Package for Social Sciences (SPSS) version 23.0 was used for data analysis. The association between selected factors and depression was tested using the Chi-square test at a significance level (p-value) <0.05. PHQ-9 instrument scores (not at all “0”; few days “1”; more than half the days “2”; nearly every day “3”) were used. A total score less than 4 signifies no depression, 5-9 signifies mild depression, 10-14 signifies moderate depression, 15-19 signifies-moderately severe depression, and 20-27 signifie-ssevere depression.

Ethical Considerations

Ethical approval was obtained from the Human Research and Ethics Committee of Lagos University Teaching Hospital (LUTH), Lagos State. In addition, permission was requested from the DOTS centers for this study and was obtained from the Lagos State Primary Healthcare Board and the Lagos State Hospital Service Commission. Voluntary consent after informed decision from the participantswas also requested and obtained.

From the 342 calculated sample size, an 88% response rate was recorded as only 301 TB patients responded. The obtained results are expressed as follows:

Table 1: Socio-demographic characteristics of respondents.

The mean age of the participants was 35.2±11.75 years. Age group 21-30 yearswas the largest 114 (37.9%), males were more - 216 (71.8%), 153 (50.8%) were single, 6 (2.0%) were divorced, 3 (1.0%) were widowed,and 1 (0.3%) was separated. On the religion of the study participants, 69.1% were Christians, 29.9% were Muslims, and others were traditionalists (1%).Yorubaethnic group had the highest number of participants (52.2%). The employed versus unemp-loyed was 50.5% versus 49.5%.Participants with monthly income between N30,000-N100,000 were most (51.0%). Most participants were from a nuclear home (59.1%) and just one participant (0.3%) had no formal education. Fig. 1 illustrates a 51.8%prevalence of depression among the respondents. 156 out of the 301 respondents were depressed. This ratio was calculated from the PHQ-9 used to determine depress-sion among the participants.

Fig. 1:  Prevalence of depression among the respondents.

Fig. 2 shows the severity of depression among the 156 depressed respondents. 41.03% were mildly depressed, 39.1% were moderately depressed, 14.1% hadmo-derately severe depression, and 5.77% were severely depressed.

Table 2 shows the knowledge of depression among the respondents. 86 (28.6%) of the respondents have not heard of depression, while 215 (71.4%) have heard about it. 211 (70.1%) knew that depression can cause suicide, 146 (48.5%) knew that marked loss of interest is a symptom of depression, while only 69 (22.1%) believed it could be cured using unorthodox medicine, and 172 (57.1%) agreed that it can also be treated with talk therapy.

Fig. 2: Depression severity among the depressed respondents.

Table 2: Knowledge of depression among the respondents.

Fig. 3 illustrates that only 24.6% of the participants had an above average (good) knowledge of depression, 42.9% hadan average (fair) knowledge of depression, and 32.6% had a below average (poor) knowledge of depression.

Fig. 3: Level of knowledge of depression among the respondents.

Table 3: Attitude of the respondents towards depression.

The table above shows that 173 (57.5%) respondents agreed that depression is a sign of personal weakness and 139 (46.2%) agreed that it is not a real medical illness. 187 (62.1%) agreed that people with depress-sion can get over it if they want to, and 123 (40.9%) respondents disagreed that if they had depression, that they would not tell anyone. Fig.  4 reflects the attitude of the respondents towards depression. 41.0% of the respondents had a positive attitude while 59.0% had a negative attitude towards depression.

Fig. 4: Attitude towards depression among the respondents.

Some of the factors associated with depression in TB 

patients are shown in Table 4A and continued in Table 4B.

Table 4A: Factors associated with depression among respondents.

Table 4B: Factors associated with depression among respondents (continued).

Tables 4A and B show the relationship between factors associated with depression and depression. 38.0% of the respondents who agreed life was not difficult were depressed, and 7 out of the 9 respondents who confirmed life was extremely difficult were depressed. 60.7% of patients with TB symptoms were depressed. 63.4% of respondents who experienced stigma from family and friends were depressed, while 50.4% of the respondents without the experience of stigmatization from family and friends were depressed as well. Half of those (50.0%) who do not think TB can make someone depressed were depressed. 64.9% of HIV-positiveTB patients were depressed. 73.3% of those diagnosed with TB for more than 12 months were depressed. 66.7% of the respondents with treat-ment failure were also depressed. 7 out of 8 respon-dents who experienced hostility from treatment center staff were depressed. 64.9% of those concerned about privacy at treatment centers were depressed. 84.6% of those whom their family were not supportive were depressed, and 52.8% of those who do not belong to any social support group were depressed.

Studies have been conducted on tuberculosis and how closely related depression is to it. Reports have also shown that there is an increase in the incidence of tuberculosis (Emery, 2021; WHO, 2023a).The mean age of the participants in this study was 35.2±11.75 years.Most (83.7%) of the patients (participants) were 21 to 50 years old, suggesting that the workforce population has the highest TB infection compared to those below 21 years and beyond 50 years. Males are more infected in this study, similar to the studies of (Dahiya, 2017) and (Salodia, 2019).An interpretation of this could be that men interact more with people or strangers than women. In agreement with (Dahiya, 2017) study, the single or unmarried participants were 50.8%, suggesting a broad range of interaction for unmarried people compared to the married, divorced, widowed, or separated. Majority of the respondents were Christians (69.1%) and over half were Yorubas (52.2%). These indicate that Christianity and Yorubas were the dominant religion and tribe respectively among the TB patients in Lagos State. Unemployment was high with a 49.5% incidence. However, the incidence of tuberculosis is almost equal between the employed and unemployed. The state government has to channel more resources to employment. Tuber-culosis is highest among people with a monthly income ≤N100,000, supporting the study of (Dahiya, 2017) where low-income earners dominated the tuberculosis-infected population. From this present study, it is proven that tuberculosis is available across every education level. There is limited information on the knowledge of depression among tuberculosis patients. This present study reported that 24.6% respondents had an above average (good) knowledge of depression, 42.9% had an average (fair) knowledge, whereas 32.6% had a below average (poor) knowledge of depression. It was discovered that 71.4%have heard of depressionand 70.1% know that it can cause suicide. More than half of the respondents believe that it is not a common psychiatric disorder. 61.1% know that tuberculosis can cause depression while over half were not sure that depression can be caused by biological factors such as genes (74.1%), birth of a baby (72.4%), and old age (62.1%). In addition, participants were admirably knowledgeable of the symptoms of depression. Surprisingly, 72.1% believed a depressed person should see a doctor, one-third thinks that religious leaders should be sought for help and a lesser number believe it should be a family member. More than half of the respondents believed that depression can be treated with talk therapy (57.1%), getting involved in physical activities (56.1%), and pulling yourself together (58.8%). In summary, the level of knowledge of depression among the participantscan be said to be average (fair), which may be due to low education on depression in treatment centers or poor public enlightenment on tuberculosis. Positive attitude was exhibited by 41.0% of the participants while 59.0% had a negative attitude towards depression. Hence, there was a general negative attitude towards depression among the respondents. More than half of the respondents had a negative attitude towards depression which agrees with the literature which says that knowledge and attitude go hand-in-hand. A lower level of knowledge tends towards a more negative attitude as seen in this present study. Most respondents agreed that people with depression could get over it if they want to (62.1%), and 40.9% agreed that they would tell someone if they were depressed. A good number of the respondents agreed depression is a sign of personal weakness (57.5%), that it is not a real medical illness (46.2%), and that they would not vote for a politician if they knew he/she had been depressed (43.2%).

This present study recorded a51.8% prevalence of depression among TB patients, a value higher than 23.6% in New Delhi, India (Salodia, 2019) and 30% in Lesotho (Larson, 2017). The value is close to 51.9% in Eastern Ethiopia (Dasa, 2019), and lower than 80% in Pakistan (Anwar, 2010). All these countries of study are developing countries with financial crises. The variation in the prevalence of depression could be attributed to various factors as described in the follo-wing paragraphs. There was a statistical association (significance) between depression and socio-occu-pational dysfunction (p=0.000). 59 (72.0%) of those whofoundlife somewhat difficult were depressed, 20 (76.9%) of those who expressed finding life very difficult were depressed, and 7 (77.8%) of those who-found life extremely difficult were also depressed. TB is a debilitating illness with high morbidity. This may make coping with general activities difficult and a patients extent of inability to cope may influence his vulnerability to depression. Depression was significant for TB patients being strongly affected by symptoms of TB (p=0.015). 85 (60.7%) of the participants who had TB symptoms (particularly coughing and weight loss) were depressed. This finding is similar to the report of (Baba, 2009) where persistent cough among tuberculosis patients was significant for depression.It is easy for symptomatic patients to elapse into depression because of the negative reactions from people whom they interact with especially extreme weight loss and persistent coughing in public.The duration of the treatment of tuberculosis is also significantly associated with depression (p=0.020) as 90 (57.3%) of those in 4-6months of therapy and 9 (75.0%) of those on therapy for more than 12 months were depressed. This is consistent with the findings from two different studies done in Ibadan (Ige, 2011) and Enugu (Aniebue, 2007). This may be because having to take drugs for a prolonged time consistently may be distressing to the TB patients. However, new findings of associated factors not seen in other studies were found in this study. For example, depression was found to be significantly associated with the experi-ence of stigma from family and friends (p=0.008). 59 (63.4%) of those who said family and friends kept their distance were depressed. Any form of stigmatization (perceived or real) may contribute to developing depression. Denial of certain privileges in the comm.-unity was also statistically associated with depression (p=0.001) as 31 (77.5%) of those experiencing denial of privileges in their communities were depressed. In addition, the association between depression and HIV-TB comorbidities was significant (p=0.014). This finding was also reported in Ethiopia (Adem, 2014). This is only natural as the burden of these two major diseases can be particularly frustrating, distressing and discouraging. Furthermore, depression was signifi-cantly associated with privacy concerns in treatment centers (p=0.002) as 74 (64.9%) of those who expressed concern for privacy in treatment centers were depressed. This is only natural as people feel uncomfortable being identified as TB patients in public. Finally, there was a statistical association (significance) between depression and family support (p=0.017) as 11 (84.6%) of those receiving no support from family were depressed. Majority of the respondents do not belong to any social support group (52.8%) and were depressed, although the association was not significant. Lack of social support groups in treatment centers and family support may contribute to depression as there would be no platform for worries and anxieties to be calmed. Other factors that were not significantly associated with depression include thought that tuberculosis makes one depressed, period of being diagnosed with tuberculosis, stage of treat-ment, distance to treatment center, attitude of treatment center staff, and time spent on a treatment day. 

Tuberculosis is a chronic debilitating infectious disease of global public health concern and ending the global tuberculosis burdenneedsthe translationinto action of the commitments highlighted at the 2023 United Nations high-level meeting on tuberculosis.

Authors declare that they do not have any conflict of interest.