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

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:  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

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 SD Range Household size Mean SD Range

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 ( ) 5.4 ( ) Middle 3.9 ( ) 3.1 ( ) Higher 1 1 Occupation Unemployed 9.5 ( ) 9.2 ( ) Lower 6.0 ( ) 4.4 ( ) 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 ( ) 3.0 ( ) No 1 1 Difficulty in financing treatment Yes2.6 ( ) 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 Poor5.0 ( ) Medium2.9 ( ) Good 1 Literacy Illiterate 2.5 ( ) 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