THE EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY TO REDUCE TUBERCULOSIS SELF-STIGMA: A LITERATURE REVIEW

Tuberculosis is an infectious disease with severe stigma. It is estimated that half of TBC patients have experienced internalization of stigma due to negative stereotypes from their community. The purpose of this review article review was to determine and to assess the effectiveness of cognitive behavioral therapy in reducing tuberculosis self-stigma. PRISMA flow diagram was used to show papers reviewed. Database used consisted of ProQuest, Science Direct, PubMed, Research Gate, Springer Link, and Google Scholar using keywords: CBT, AND Self Stigma, Cognitive behavioral therapy to reduce self stigma, CBT OR Self Stigma, Self-stigma AND CBT Intervention. articles published in English m 2003 to 2018 discussing HIV-related stigma and discrimination on patients with TB. Out of 15245 articles retrieved, 6% (4 articles) were reviewed. This review article using Downs and Black scale apprised the quality of the selected articles. Analysis method used thematic analysis and found stigma intervention as a theme. The results found four studies about the effectiveness of cognitive behavioral study and one study comparing cognitive behavioral therapy with psychoeducational (PE) found to be more helpful than CBT intervention. In another article showed more than a half of the sample (50%) from studies indicated that cognitive behavioral therapy can reduce self-stigma. Using cognitive behavioral therapy is effective for helping TBC patients to change negative beliefs and reframe their beliefs about their illness and the effect can help to reduce self-stigma.


INTRODUCTION
Indonesia is one of the five countries with the highest tuberculosis cases (Kemenkes RI, 2015;WHO, 2017).
The estimated prevalence of tuberculosis disease in Indonesia in 2016 was reported to be 395 new cases per 100,000 people,and as many as 10.4 million people with 1,2 million new cases every year (WHO, 2018). There was an increasing prevalence of TBC due to negative stereotyping of TBC patients by the community that was internalized by TBC patients. Internalized stigma is a significant predictor that takes place due to discrimination which hasnegative effect on patient's social function.
Stigma is influenced by social, and financial factors. TBC stigma involves negative stereotype, prejudice, and discrimination (Moriarty, Jolley, Callanan, & Garety, 2012). There are many TBC patients who survived their illness and community isolation. The negative stereotype is related to immortality behavior, hedonism, poverty, maginalized groups, sex worker and people with HIV/ AIDS (Cremers et al., 2015;Sommerland et al., 2017;Hague, 2017  This showed that cognitive-behavioural therapy literacy significantly reduced personal stigma, although the effects were small. BluePages had no effect on perceived stigma and MoodGYM was associated with an increase in perceived stigma relative to the control. Study research by Shimotsu et al., 2014 showed that the cognitive bias was significantly correlated with-self stigma. In other study, cognitive therapy appeared feasible and acceptable to reduce stigma in people with psychosis who have high levels of internalised stigma. One study showed that cognitive behavioral therapy (CBT) alone was not as effective in reducing self-stigma as compared to using a combination of CBT and PE (Morrison et al., 2016;Wood et al., 2018).

Quality assesment
The author found a general lack of quality in intervention to reduce self-stigma which can be applied to TBC patients with selfstigma. There are no established quality criteria, the total possible score to give an indication of quality using Downs and Black Checklist (Studies, 2008) (Table 1). This randomised controlled trial demonstrated that, relative to an attention control group, both a webbased depression literacy intervention and a web-based cognitive-behavioural intervention resulted in a small but statistically significant reduction in stigmatizing attitudes towards depression among people with high levels of depressive symptoms.

2.
Shimotsu The PE intervention appeared more helpful than the CBT intervention on some outcomes, however due to the small sample sizes no specific inferences can be made and further large-scale research would be required.

DISCUSSIONS
TBC patients who have high levels of stigma were more likely to have greater depression and related mental health problems. Therefore, the care of TB patients should also include mental healthcare due to the existence of TBC stigma and depression (Lee, Tung, Chen, & Fu, 2017). Self-Stigma on TBC is one of the things that have effect on global TBC goals due to emotional effect in TBC patients which make them isolate themselves. Self-stigma is related to decreased self-esteem, self-efficacy, decline in social adaptation, and severe depressive symptoms (Fung, Tsang, & Cheung, 2011;Shimotsu et al., 2014).  (Watson et al., 2007).
Another article review showed CBT is one of the strategies intervention to reduce TBC stigma (Heijnders, 2015).  (Newcomb et al., 2015). Short course of group CBT treatment is effective in improving social behaviour which may reduce self stigma that causes social isolation (Wykes et al., 2005).
The limitations of this study need to be considered when interpreting the findings.
First, this study only used 4 articles in English, which may include inclution criteria and data was largely so this study is not able to group intervention types on stigma types.