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