Socioeconomic Position and Adherence to Tuberculosis Treatment A by tracy12

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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)
                   Crude                   Reduced 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)
                     Crude                 Reduced 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

								
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