Tuberculosis and depression: cultural dynamics of comorbidity among Pashtun communities in Pakistan and Afghan refugees

Abstract Objectives Tuberculosis (TB) remains a significant global health challenge, ranking among the top ten causes of death worldwide. Pakistan is the fifth-highest burden country for TB globally. Patients with TB often develop depression, where cultural factors play a profound role. This study explores the cultural perceptions and beliefs that influence TB-depression comorbidity among the Pashtun ethnic population of Pakistan and Afghan refugees, with a broader aim of developing a culturally appropriate intervention for the treatment of depression in TB. Study design We conducted a qualitative study across TB treatment centres in the Haripur and Peshawar districts of Khyber Pakhtunkhwa, Pakistan. Methods The study comprised 29 in-depth interviews and 11 focus group discussions, involving 101 participants across three groups: healthcare providers, TB patients, and carers. We analyzed the data using a deductive-inductive thematic analysis approach and employed the Southampton framework for cultural adaptation of interventions. Results We identified four central themes. The first theme described the cultural norms of the region, which influence physical and psychological conditions related to TB and depression. The second theme highlighted the role of the belief system in relation to the TB-depression comorbidity. The third theme explained the existing stigma associated with TB and depression. The last theme informed the development of a culturally appropriate psychotherapy-based intervention. Conclusion Gender disparities, social stigma, family dynamics, lack of social support, and belief systems are culturally driven issues linked to TB-depression comorbidity. Psychosocial interventions must consider and integrate the socio-cultural context of the target population.