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Socioeconomic Position and Adherence to Tuberculosis Treatment: A case-control Study Mishra P, 1 Hansen EH, 1 Sabroe S 2 1 Dept of Social Pharmacy, Danish University of Pharmaceutical Sciences, Copenhagen, Denmark 2 Dept of Epidemiology and Social Medicine, Aarhus University, Aarhus, Denmark
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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
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Objective To analyse the association between socio-economic position and patients’ adherence to anti-TB treatment under DOTS
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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
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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: F ace-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
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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
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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 42.938.7 SD 18.216.3 Range 17-7715-76 Household size Mean 4.24.5 SD 2.11.8 Range 1-91-9
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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
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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 Yes2.6 (1.1-5.9) No 1
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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 Poor5.0 (1.3-18.8) Medium2.9 (1.1-7.7) Good 1 Literacy Illiterate 2.5 (1.1-5.4) Literate 1
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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
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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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