How culture shapes tuberculosis and depression in Pashtun communities

Tuberculosis remains one of the world’s deadliest infectious diseases, and Pakistan is among the countries hit hardest. Beyond the physical toll of TB, many patients also develop depression, and researchers led by Fayaz Ahmad set out to understand how culture shapes that overlap. The team focused on the Pashtun ethnic population of Pakistan and Afghan refugees, groups with strong local traditions, beliefs, and family structures that can affect how illness is experienced and treated. To learn what matters most to patients, their caregivers, and the health workers who treat them, the researchers worked in TB treatment centres in the Haripur and Peshawar districts of Khyber Pakhtunkhwa, Pakistan. Their aim was practical: to gather the cultural insights needed to design a psychotherapy-based intervention that would fit local realities. Rather than testing a drug or a device, the study explored everyday experiences, beliefs, and social pressures that shape both physical illness and mental health, with the goal of making future depression treatments for TB patients culturally appropriate and more likely to be accepted and effective.

This was a qualitative study that interviewed a wide range of people to capture different perspectives. The team conducted 29 in-depth interviews and 11 focus group discussions, involving 101 participants across three groups: healthcare providers, TB patients, and carers. They analyzed the conversations using a deductive-inductive thematic analysis approach to identify patterns and meanings in what people said. To guide the shape of a suitable treatment, the researchers employed the Southampton framework for cultural adaptation of interventions, a structured way to tailor psychosocial programs to local culture. The analysis produced four central themes. First, local cultural norms influence both physical and psychological reactions to TB. Second, belief systems — including explanations for illness and expectations about recovery — affect how depression and TB are understood. Third, stigma around TB and depression shapes people’s willingness to seek help. And fourth, these findings pointed toward how a psychotherapy-based intervention could be adapted to fit this community.

The study highlights that the link between TB and depression cannot be separated from the social world in which patients live. Gender disparities, social stigma, family dynamics, lack of social support, and local belief systems were all identified as culturally driven issues connected to TB-depression comorbidity. That means simply offering standard mental health treatments may not reach many people unless those programs are adjusted to respect local values and realities. Practically, the findings argue for psychosocial interventions that integrate family roles, address stigma directly, and align with community explanations of illness so patients and caregivers are more likely to accept and use them. For health services, the message is clear: mental health care for TB patients should be designed with close attention to culture, and any psychotherapy offered should be adapted rather than imported unchanged, to improve uptake and outcomes among Pashtun communities and Afghan refugees.