Patients’, caregivers’ and healthcare workers’ perspectives on integrating anxiety care in tuberculosis services in Pakistan: a qualitative interview study

Up to 80% of active tuberculosis (TB) patients experience anxiety, threatening their treatment outcomes. The National TB Control Programme in Pakistan currently only provides mental health services for patients with multi-drug resistant TB, leaving those with drug sensitive TB (DSTB) unsupported. This study explored (1) experiences of anxiety and self-managed coping strategies used by patients with DSTB and their caregivers (2), current practice for the management of anxiety in DSTB patients, and (3) challenges and opportunities for implementation of an integrated care package for the management of anxiety in DSTB patients. Face-to-face interviews were conducted with nine healthcare workers, one service manager, 12 patients with DSTB and nine caregivers working in or attending four basic management units offering DSTB services in one province in Pakistan. The capability-opportunity-motivation-behaviour model was used to explore challenges and opportunities for implementation of the integrated care package. The data were analysed using framework analysis, then triangulated across participant groups. All participant groups acknowledged that DSTB patients experience poor mental health including anxiety. Indeed, they needed prompting to focus on anxiety. No patients or caregivers had discussed anxiety in their TB consultations, instead patients used their own coping strategies and relied on caregiver support. Healthcare workers and the service manager reported a lack of guidelines and training. They used intuition and their own counselling strategies. All participant groups supported the idea of an integrated care package (high motivation), to improve patient well-being and aid recovery. Healthcare workers were highly motivated to deliver it themselves. In terms of capability and physical opportunity, healthcare workers recognised their lack of knowledge and skills, seeing training, resources, and protocols as essential. High patient workload and limited time in TB consultations were key barriers. Face-to-face appointments lasting less than 30 min on days when patients were already attending the facility were recommended. This study provides important insights on feasibility and acceptability to inform the future implementation of an integrated package for anxiety management into routine DSTB services.