Tuberculosis (TB) is a contagious bacterial infection that attacks the lungs and may consequently spread to other organs [1]. In this paper, TB refers to a condition diagnosed by GeneXpert sputum, with results revealing the detection of Mycobacterium TB and Rifampicin sensitivity. Tuberculosis is listed among the highest prevalent epidemics in South Africa [2]. Numerous academic’s [3] proffer that TB incidence has been on the decline in South Africa since 2009, and that deaths attributed to TB have lessened significantly in recent years. The decrease in TB mortality is due to effective diagnosis and treatment, during which sputum smear conversion has a vital role to play. Sputum smear conversion during PTB treatment reveals a patient’s response to therapy and determines the direction of TB patient care [4].

Furthermore, sputum smear conversion, as part of observing the efficacy of TB treatment and reduction of infectiousness, essentially decreases the burden of disease [5]. The management of patients with TB relies largely on the smear microscopy results [6]. Sputum smear conversion after two months is thus an important indicator of the progress in TB treatment.

The results of the sputum smear at the end of the intensive phase give guidance to clinicians on whether the patient should be switched to the continuation phase or whether the intensive phase should be extended for another month [7-9]. This suggests that a delay in sputum conversion to negative increases the rate of relapse and can lead to the occurrence of drug-resistant TB (DR-TB) [10]. To combat occurrences of relapse, various measures have been put in place by the National Department of Health (NDoH) to manage TB and to reach its targets at the same time. The measures include assigning patients to a treatment supporter, who might be a community health care worker or a family member. The treatment supporter is given health education about the TB disease, the treatment that the patient is taking and the duration thereof, the patient's follow-up dates, and is advised to report the challenges the patient might be facing. Furthermore, the patients' psychosocial, economic and health challenges that might hinder the patient’s progress to treatment must be discussed as the patients come to the health care facility. Hence, a multidisciplinary team meeting is encouraged to develop problem-solving strategies.

However, the researchers have observed that the Ekurhuleni Health District, in particular, does not meet the NDoH’s set targets, particularly because non-conversion at 2 and 3 months of TB treatment is still high among some patients attending primary healthcare facilities in the Ekurhuleni Health district.

The National Tuberculosis Management Guideline (NTMG) 2014 in South Africa states that in patients with TB, sputum smear must be collected for conversion at two months of treatment. Patients with TB are expected to have conversion at two months of treatment to show effectiveness of the TB treatment. Patients’ results identified as non-conversion at two months or three months of treatment is a challenge in TB management control. As for the above statements, at Ekurhuleni Health district, the District Health Information System (DHIS) statistics from 1^st April 2017 to 31^st March 2019 showed most patients as having non-conversion at two and three months of TB treatment.

During the period noted above, 5791 patients were diagnosed with TB as new or re-treatment; the patients’ sputum smear was positive. The District TB conversion report showed that out of 5791 diagnosed with TB, 3216 patients had conversion at 7 weeks of treatment. Also, among them, 1508 patients had non-conversion by the 7^th week of the treatment, and 792 patients were not evaluated (meaning that the sputum was either not collected or results were not captured in the TB system). About 116 patients died before conversion date, while 74 patients were transferred to other provinces or other districts’ health care facilities before the conversion period. In addition, a total number of 82 patients were Lost to Follow (LTF) or treatment interrupters, meaning that the patients were no longer able to access their patients with TB in the health care facilities. Furthermore, it was indicated that there was no patient who progressed to multi-drug resistance TB (MDR-TB).

As per the NTMG, patients must be given an extra month in the intensive phase of TB treatment if they had non-conversion at two months. Patients’ reasons for non-conversion must be identified and addressed, and then another sputum by week 11 must be collected from the patients. A challenge identified in the report was that there were 1508 patients during the first 11 weeks of patient TB treatment. Of the 1508 patients, only 638 patients' sputa conversion was negative, 291 remained positive, 550 patients' sputa were not evaluated, and seven patients died before their sputa were collected. Moreover, four patients were moved to other facilities in the district, while 15 patients were LTF, and three were diagnosed with MDR TB. From the above, there is a need for further exploration of the factors contributing to the non-conversion of patients on PTB treatment at Ekurhuleni district clinics.

Non-conversion is defined as a process whereby the sputum smear remains positive at the end of an intensive phase of treatment (2 months for new cases and 3 months for re-treatment cases) [11]. In this paper, the term ‘non-conversion’ refers to patients who started TB treatment at 2 or 3 months and did not experience conversion to the continuation phase. Against this background, this research article aims at exploring and describing the patients’ perceptions of the factors contributing to patients with TB non-conversion at selected healthcare facilities in the Ekurhuleni Health District, Gauteng, South Africa. It is envisaged that the results and recommendations of this study will benefit both the professional nurses during nursing practice and patients by assisting in facilitating the understanding of the factors that contribute to TB non-conversion at 2 or 3 months of treatment. The patients are the people who are either receiving or are registered to receive TB treatment [12]. In this article, patients refer to the clients visiting the selected Ekurhuleni healthcare clinics for TB management and collection of medication.

Factors that contribute to patients with TB non-conversion during treatment are partly responsible for the continued prevalence of the TB disease [13]. Factors contributing to non-conversion of patients with TB have been highlighted in a number of research-based articles. For instance, a study conducted in China [14] reported an association between smoking history and sputum smear non-conversion. In the same vein, Siddiqui et al. [15] found that smokers on TB treatment were associated with delayed sputum smear conversion at 8 weeks. Visser et al. [16] also found that a positive smoking history was associated with delayed sputum smear conversion in South Africa.

Individuals with positive smoking history are likely to have a radiologically extensive disease, which some studies have associated with sputum smear non-conversion [14, 15]. A study conducted in China [17] indicated a connection between TB prevalence, poor working conditions and relocation to access job-related opportunities. In that study, the participants reported that they were non-adherent to TB treatment due to their movement from one place to another. Poor working conditions were mentioned as the main reason that compelled them to relocate to other countries. As such, the participants either forgot or stopped taking treatment because they did not have referral letters or other documentation required for their treatment.

Language barriers between patients and healthcare workers also contribute significantly to patients with TB non-adherence to treatment and non-conversion at 2 or 3 months of treatment. Proper and clear communication between the health worker and patient is vital, as it enables the patient to understand his or her condition and the required treatment. Hane et al. [18] conducted a study in Senegal and found that there was no proper communication between patients and healthcare providers regarding diagnosis, registration and continuity of treatment. The study also found that patients believed that after two months of treatment, they were cured since they felt better. In other words, patients did not have sufficient knowledge to discern the importance of completing treatment and that this would entail that they should complete the full course of the treatment regime. Findings from the same study also revealed that short messages given to patients with TB by healthcare workers helped to address the issues associated with TB. Thus, poor communication between patients and healthcare workers is also the cause of low health literacy among the patients.

In South Africa, low health literacy is still a major problem, and this could also be ascribed to language barriers, although health literacy is not necessarily limited to language competence. Not all patients with TB are English speakers or highly illiterate, for that matter [19]. Linguistic competence and levels of literacy are important to consider here because there is a strong relationship between low literacy and health status [20, 21].

Patients, who generally have many health problems, are less aware of preventive and curative health measures and services, which contribute to their poor health status and the adoption of unhealthy lifestyles [22]. Accordingly, because of the challenges related to health literacy, patients often have a poor understanding of the medication they are using [22]. This is one of the many challenges encountered in the South African healthcare sector. Knowledge of disease symptoms is the prerequisite for self-referral. Ignorance of the necessity for treatment compliance, coupled with inadequate knowledge about TB, was cited by 20 out of 120 TB cases, and was the most important reason for treatment default [23].

In a study conducted in the Eastern Cape, a correlation was found to exist between stigma and causes of patients with TB non-adherence to treatment/non-conversion [24]. The same study found that stigma influences PTB adherence in most patients. The patients in the same study reported that they did not feel comfortable with the way their neighbours looked at them when they went out to catch the transport service to the clinic. They also did not feel comfortable with the fact that patients with PTB were using specified rooms and assisted by nurses known to be treating patients with TB [24]. The possible influence of social stigma with regard to smear conversion can be explained by patients' fear of the loss of support, both economical as well as emotional, coupled with neglect by family and community. The interplay of these multiple social factors may lead to lower adherence to anti-TB therapy (ATT) and also nutrition deprivation due to neglect, which, in turn, may result in a delay in smear conversion, as evident in their results.

This study was conducted at selected primary healthcare facilities in the Eastern Sub-District Region of the Ekurhuleni District Municipality in the Gauteng province. The population for this research comprised patients with TB who had sputum non-conversion at 2 or 3 months of their TB treatment at the selected primary healthcare facilities in the Ekurhuleni Health District.

An explorative, descriptive and qualitative research design was adopted for this research. This design was suitable for this study, as it assisted the researchers in having a better understanding of patients’ perceptions of the factors contributing to non-conversion at 2 or 3 months of TB treatment. Non-probability purposive sampling was utilised to obtain male and female patients with TB between the ages of 18 years and 60 years.

In-depth semi-structured interviews were used to collect data from eight patients with TB at selected primary healthcare facilities in the Ekurhuleni Health District. The interviews were conducted in consultation rooms with minimal distraction. The in-depth individual semi-structured interviews provided the researcher with an opportunity to probe and investigate hidden and suppressed perceptions of the participants. The researcher recorded the interview with the consent of the participants. In-depth semi-structured interviews were conducted with guidance from the interview guide, a ‘grand tour’ question was asked, followed by probing questions following the participants’ response. The question was: Could you please share your experiences regarding the factors contributing to non-conversion during TB treatment?

The participants were encouraged to share their experiences without being intimidated by the recording and the researcher, who would be asking clarity-seeking questions and writing field notes. During the interviews, the researcher wrote field notes with the participants’ permission. In addition, an audio recorder was used to capture the participants’ oral statements during the interviews, after which they were digitally stored in a personal computer and external hard drive. The files folder was protected by a password. Verbatim transcripts, field notes and audio records were stored in the researcher’s safe to prevent access by any unauthorised persons.

Data were uploaded into a computer and then analysed using an Atlas TI data analysis computer tool Version 9 for the storage of textual data, after which Tesch’s thematic coding steps were followed. Audio-recorded interviews were transcribed verbatim, and the transcripts were stored in one folder through the Atlas TI application. The researcher read the transcriptions several times, and themes reflecting similar ideas were highlighted and grouped together in different codes. The grouping of codes was conducted electronically using Atlas TI coder. 3 themes, 6 sub-themes and 11 categories were identified in the findings.

During data analysis, the following three themes emerged in relation to factors contributing to patients’ non-conversion during TB treatment:

• Patients’ healthcare literacy
• Psychosocial support issues
• Challenges experienced by the patients

The findings of this study reveal co-morbidities and substance use as some of the contributing factors to TB non-conversion. Some participants stated that they had other conditions other than TB. A few participants stated that they were smoking while on treatment, and only one continued to smoke after receiving health education. Nurse participants pointed out that some patients were in denial, making it difficult for them to get to conversion, which has also been confirmed in the literature [41].

In this study, participants did not indicate pill burden as a factor that contributed to non-conversion to TB treatment. However, another study reported that pill burden, as well as treatment-related side effects, contributed to patients’ non-compliance [32].

Treatment compliance was stipulated by the interviewed nurses to be another important factor contributing to patients’ non-conversion, though the patients in this study stated that they were taking treatment as prescribed. The use of traditional medicine by the patients was noted by the nurse participants and confirmed by only one participant, who had used traditional medicine before accessing TB treatment. A similar study corroborated the prevalence of dual practices among patients [10].

The findings of this research suggest that health literacy is a contributory factor to patients’ non-adherence to TB treatment as it has been linked to poor understanding of the medication they are using. The lack of health literacy is one of the many challenges faced by the South African health care system today as most patients cannot read or write, which impacts their understanding of the importance of the need to complete their treatment phase. Knowledge of disease symptoms is the prerequisite for self-referral in good time. In the same vein, in another study on non-adherence to TB treatment, ignorance of the necessity for treatment compliance coupled with inadequate knowledge about TB was attributed to treatment default in 20 out of 120 TB cases and was reported as a major contributory factor to sputum non-conversion [23]. A study conducted on patients' perspective about factors associated with loss to follow-up, relapse and treatment failure in tuberculosis patients revealed that poor adherence by patients to anti-tuberculosis drugs contributes to the worsening of their TB problem and relapse and that treatment failure can harbour drug-resistant mycobacterium [42, 43].

The findings of this research indicate that social issues, such as a lack of support from the patients’ families, including nutrition-related factors, such as shortage of food and social support, are some of the challenges that cause some patients to take treatment on empty stomach, and which have proved to be detrimental to their progress as these TB drugs are supposed to be taken with food [7, 41]. Taking TB drugs on an empty stomach may cause more side effects, such as nausea and vomiting, and subsequently lead to non-adherence. Such situation was aggravated by the fact that a majority of the patients were unemployed and not receiving social grants. This was outlined by both the patients and the nurses. The WHO emphasizes the importance of ongoing nutritional assessment, counselling and addressing nutritional deficits for patients with TB. A study done on nutritional intake among patients undergoing tuberculosis treatment in Asia recommends that increasing nutritional intake, i.e., small yet regular meals which are high in protein and fresh fruits and vegetables or other snacks low in sodium and saturated fats, is important to supply additional micronutrients to patients who are on TB treatment [44]

According to the nutritional component of the TB management program in South Africa, patients must be encouraged to eat a balanced diet using readily available food, stop smoking and reduce alcohol intake. Dieticians are expected to visit the facilities for patients' nutritional support. The food parcels that are provided by the facilities include instant porridge and juice. In addition to that, the NGOs provide food packages, such as the following:

• Maize meal, instant porridge, samp, rice, bread flour, powder milk,
• Pilchard, cooking oil, soya mince and soup powder,
• Tea bags, sugar, peanut butter, salt,
• Vegetables, such as carrots, cabbage or spinach and sugar beans.

The findings presented in this study are in line with other studies, which reveal that economic challenges, job-related challenges and family support are some of the factors that affect treatment outcomes and, subsequently, sputum conversion. In a recent qualitative review, economic constraints due to absence from work to attend appointments, or the direct and indirect costs of accessing treatment, were commonly cited by patients as important barriers to completing TB treatment [45].

Stigmatisation of the patients was also mentioned by the patients and was cited as a reason why some patients were not receiving support from their family members. Health-related stigma has been defined as “a social process characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem, such as AIDS and TB. A study on stigma among patients with TB and healthy community members in Thailand has revealed that individuals diagnosed with TB report fear of isolation and rejection, including, being divorced or having marriage problems, being denied to share meals, utensils or sleeping rooms with family members, and have endured general avoidance or gossips among community members [46]. According to research, stigmatisation of patients with TB is exacerbated by the language used to label patients, such as TB patients, defaulters, as well as the obligatory screening, testing and disease notification systems that lack privacy [47].

This is a cause for concern as a study on fighting TB stigma asserts that although people with TB and policy makers have always recognised the stigma that surrounds the disease, not much has been done to confront it; instead, more emphasis has been put on the risk and fear of transmission of the airborne infection and the well-being of the public over that of individual patients [47-49].

It was also noted that, in general, the nurses did not include family members in the TB treatment process. Such exclusion poses a significant gap in the treatment process [43].

Psychosocial challenges affect patients with TB. Enhanced patient education must be offered when patients start their TB treatment. The findings of this study reveal that co-morbidities and substance use are some of the factors contributing to TB non-conversion. Some participants stated that they had conditions other than TB. A few participants stated that they were smoking while on treatment, despite them having received health education. Only one participant continued to smoke even after the second result of non-conversion. Patients were encountering social challenges, such as lack of a family support system, being stigmatised, shortage of food and insufficient social support. The findings in this study have shown that patients experienced a shortage of food, with some taking treatment on empty stomach. Most of the patient participants were unemployed and not receiving social grants, which was highlighted by both the patients and the nurses.