socioeconomic position and adherence to tuberculosis treatment: a case-control study mishra p, 1...
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Socioeconomic Position and Adherence to Tuberculosis Treatment: A case-control Study
Mishra P,1 Hansen EH,1 Sabroe S2
1 Dept of Social Pharmacy, Danish University of Pharmaceutical Sciences,
Copenhagen, Denmark
2 Dept of Epidemiology and Social Medicine, Aarhus University,
Aarhus, Denmark
Background 1/3 of world population infected with
tuberculosis (TB) 45% of Nepalese population infected with
TB Directly Observed Treatment Short-
course (DOTS) started in Nepal in 1996 and was implemented throughout the country by April 2001
However, still in 2001/2002, 6,000-8,000 people died from TB
In Nepal, 8 months treatment regimen followed for treatment of TB
Non-adherence is a principal cause of treatment failure
Objective
To analyse the association between socio-economic position and patients’ adherence to anti-TB treatment under DOTS
Methods (1)Setting : Study conducted in Kaski, a western hilly
district in Nepal TB treatment under DOTS offered by the
Regional TB Center, 2 Primary Health Centers, 8 Health Posts, 3 Sub-health Posts
Population : All sputum positive patients, whether they
completed their treatment (adherents) or not (nonadherents)
Totally, 50 non-adherent and 309 adherent patients were registered
Design: Case-control study Cases: not completed treatment Controls: completed treatment
Methods (2)Sample: 50 cases & 100 controls Controls selected randomly in the ratio of 1:2 from
adherents Non-partcipants: 20% of cases & 5% of controls
Data collection method: Face-to-face questionnaire based interviews.
Socioeconomic variables: Gender, age, marital status, literacy, occupation,
living area, caste, income, living conditions,
travel cost to the TB treatment facility, and
affordability of treatment
Methods (3)Analyses: Relationship of socioeconomic risk factors with
non-adherence (outcome) performed by cross-tabulation
Significance of risk (OR) of becoming non-adherent was calculated by Chi-square & Chi-square trend tests
Means calculated by independent sample t-tests Bivariate and multivariate analyses performed to
identify factors associated with nonadherence
Table 1: Background Characteristics of respondents
Case (n=40) Control (95)
Types of TB
Category I 80.0% 73.7%
Category II 20.0% 26.3%
Age (years)
Mean 42.9 38.7
SD 18.2 16.3
Range 17-77 15-76
Household size
Mean 4.2 4.5
SD 2.1 1.8
Range 1-9 1-9
Table 2: Risk of non-adherence to anti-TB treatment by socio economic position estimated from multivariate logistic regression analysis (N=129)
CrudeReduced Model
Risk factor OR 95% CI OR 95% CI
Annual income
Lower 6.3 (1.3-29.2) 5.4 (1.0-30.0)
Middle 3.9 (0.8-19.0) 3.1 (0.5-17.8)
Higher 1 1
Occupation
Unemployed 9.5 (3.2-28.5) 9.2 (2.8-29.8)
Lower 6.0 (2.2-16.0) 4.4 (1.5-12.5)
Higher 1 1
Table 2: Risk of non-adherence to anti-TB treatment by socio economic position estimated from multivariate logistic regression analysis (N=129)
Crude Reduced Model
Risk factor OR 95% CI OR 95% CI Travel cost to reach TB treatment facility Yes 3.2 (1.5-7.1) 3.0 (1.2-7.3) No 1 1 Difficulty in financing treatment
Yes 2.6 (1.1-5.9)
No 1
Table 2: Risk of non-adherence to anti-TB treatment by socio economic position estimated from multivariate logistic regression analysis (N=129)
CrudeReduced Model
Risk factor OR 95% CI OR 95% CI
Living conditions
Poor 5.0 (1.3-18.8)
Medium 2.9 (1.1-7.7)
Good 1 Literacy Illiterate 2.5 (1.1-5.4) Literate 1
Key Lessons Learnt:
Even in DOTS and with free drugs, low socioeconomic
position is an important risk factor for nonadherence, esp
lack of cash in hand
Implications & Recommendations: Raises pertinent issues “Are DOTS and free distribution of
anti- TB drugs enough to make patient adherent towards
their treatment?”
Considerations of indirect costs in addition to direct costs
are important in National TB control programmes in poor
countries
Research on other aspects needed to get fuller
understanding of the lack of success of the DOTS
strategy, for example
Norms and values in local community
Health care providers’ attitudes, values and
behaviour
Meaning of treatment from the patients’ own
perspective