Intersections of informal work status, gender and tuberculosis diagnosis: Insights from a qualitative study from an Indian setting

Background: There is evidence that more than one third of tuberculosis (TB) cases in India go undiagnosed each year and it is more pronounced among female patients. While there are studies available on the socioeconomic, cultural and gender-related dimensions of TB diagnosis delays among female patients in India, intersections of gender, informal work and diagnosis delays are not sufficiently studied. The present study aims to fill this gap by examining the TB diagnosis delay that are linked to the contingencies of working in informal arrangements for women from lower socio economic background. Methods: The study draws on 80 qualitative in-depth interviews conducted among female patients from lower socio-economic background, who were working or recently stopped working in informal arrangements and undergoing Directly Observed Therapy, Short-course (DOTS) treatment in Bengaluru (India) city and 60 willing significant others of the patients. The participants were identified through a scoping survey that covered 188 female patients from 18 DOTS centres in the city. Findings: Other than the already known reasons for the delay in TB diagnosis for women such as normalisation of symptoms, stigma and the gender-related discrimination leading to low prioritisation of women’s illness, the present study identifies reasons related to work informality. These are normalisation of symptoms as workplace health problems; work related concerns that restricted formal help seeking; non TB specific narratives of symptoms, often incorrectly assumed to be work related health issues or comorbidities and thus confounding the early accurate diagnosis by the medical personnel and shifting between formal and informal systems of help-seeking. Further, the study found that mere knowledge of TB symptoms did not always translate to early diagnosis for patients from the lower socioeconomic groups working in informal arrangements due to the fear of losing work and wages owing to hospital visits. Conclusions: The workplace focus, especially the informal sector where a huge majority of India’s workforce is employed, is notably absent in the TB elimination programme. The study indicates the need to adopt a comprehensive approach in the ongoing TB elimination programme in India in which family, living environment and workplace should be integral parts.