An epidemiological study of newly diagnosed sputum positive tuberculosis patients in Dhubri district, Assam, India and the factors influencing their compliance to treatment

Abstract

Context:

Tuberculosis (TB) affects the economically productive age group and has emerged as a disease of significant socio-economic global burden.

Aims:

The aim of this study is to identify epidemiological factors responsible for TB and the clinico-social correlates influencing their compliance.

Subjects and Methods:

All new smear positive TB (NSP-TB) patients registered in Dhubri District Tuberculosis Center-Tuberculosis Unit during 2007 in Assam were included in this study. The study was performed by interview technique using a pre-tested questionnaire.

Results:

Nearly 90.76% of the participants were in the age group of 15-55 years and were predominantly unskilled workers and sole earning member of their family. 83.33% of the patients had symptoms of cough for more than 3 weeks and most of them (98.15%) lived in overcrowded houses. More than half of the patients had X-ray examination as their initial approach to diagnosis. More males (59.18%) than females (40.82%) reported to the health institution within first 6 weeks after the onset of symptom and among them 91.84% were declared cured after completion of therapy and while, only 40% of the patients initiating treatment after 6 weeks of the onset of symptoms were declared cured after completion of therapy.

Conclusions:

The prevalence of NSP-TB cases was more among the illiterate and underprivileged population who needs counseling and motivation for early intervention.

INTRODUCTION

Tuberculosis (TB) affects the economically productive age group and has emerged as a significant cause of socio economic burden. Many Indian children have to leave school permanently and have to take up jobs in order to supplement the household income because of their parent's TB and more women were rejected by their families because of having TB.[1,2] There are clear associations between risk of TB with malnutrition and overcrowding. Although TB is not exclusively a disease of the poor, deprivation associated with poverty increases the risks of infection and development of disease.[3] TB also has a downstream impact on the impoverishment of patients and their households.[4,5] Studies in both high income and low-income countries (USA, United Kingdom, Germany, Norway, Vietnam, Mexico and Philippines) reveal significantly higher rates of TB in poor populations.[6,7,8] This study was conducted with the objective to find out the various epidemiological factors contributing to TB in new smear positive (NSP) patients registered under directly observed short course therapy (DOTS) in Dhubri District TB Center-Tuberculosis Unit (DTC-TU) during the year 2007 and also identify the different factors influencing their compliance to treatment.

SUBJECTS AND METHODS

This is a qualitative study carried out among all the 54 new smear positive-TB (NSP-TB) patients registered under DOTS in DTC-TU during the year 2007 in Assam, India. The data collection tool used for the study was an interview schedule that was developed by the investigators with assistance from other experts. “Socio-demographic and clinical data was collected using a pre-tested structured questionnaire. The study conformed to the Helsinki declaration and Institution Ethical Committee approved the study. All the participants were motivated, explained, ensured strict confidentiality and then informed consent was taken from each participant. The addresses of the patients were collected from the TB Register of the TU of District TB Centre, Dhubri, Assam, India. A maximum of five visits were arranged for those who could not be contacted during the first visit. Data was collected by interviewing the cases (n = 54) using the interview schedule at the patient's residence in a relaxed and conducive atmosphere. The results are expressed in percentages represented by tables and statistically analyzed using Chi-square test. The statistical analyses were performed by using GraphPad In Stat “version 3” software for Macintosh (GraphPad Software, Inc. 5755 Oberlin Drive #110 San Diego, CA 92121, USA).

GraphPad Software, Inc. 5755 Oberlin Drive #110 San Diego, CA 92121 USA

RESULTS

Nearly 90.76% of patients in our study were in the age group of 15-55 years, two- thirds were in 15-35 age groups and 61.11% were from Muslim community. The trend of TB was observed to be decreasing with the increase in age and males outnumbered the females except among Muslim patients where female patients outnumbered the males. 57% patients were illiterate; 12.97% had primary school level education and none of the patients had any college education. 77.77% patients were married and 64.82% patients lived with more than six family members. Nearly 51.85% of patients were sole earning member of their family, 48.15% were unskilled workers, 42.59% were unemployed and 9.26% were semi-professionals and skilled [Table 1].

Table 1.

Socio-demographic distribution of the study participants

Nearly 83.33% patients had clinical symptoms of only “cough for more than 3 weeks” while 1.86% patients presented with fever as sole symptom. 35.19% of the study population had given positive history of contact with a known diagnosed case of pulmonary TB and 40.74% of patients reported smoking habit. While 9.26% and 1.85% of the study population reported habits of both smokeless tobacco and smoking together and alcohol respectively. Regarding parameters of healthful housing,[9] 90.74% of the houses were not pucca (concrete), while 70.37% and 74.07% of the houses were not having adequate ventilation and lighting respectively and 98.15% of the houses were overcrowded, a significant risk factor for development of TB.[10] More than half of the study population (55.56%) had X-ray examination and the rest (44.44%) had Sputum examination as the initial approach to diagnosis [Table 2]. Majority of the study population (88.89%) were motivated for treatment by health workers and the rest (21.11%) were motivated by household members or neighbors. 90.74% (49) of the study subjects came for treatment within first 6 weeks of the onset of symptom. There were more males (59.18%) than females (40.82%) reporting to the health institution within 6 weeks to 6 months of the onset of symptoms. Among the study participants who came for treatment within first 6 weeks after the onset of symptoms, 91.84% were declared cure, whereas only 40% of the patients who came for treatment from 6 weeks to 6 months after the onset of symptoms were declared cured by recommended treatment. Among the 47 patients (87.03%) who were available for end treatment sputum testing, it was observed that except 1 case, all 46 patients (85.18%) were sputum negative. Out of the total 28 patients (51.85%) who had irregular treatment, 10.71% had irregular treatment due to long distance; 32.13% patients experienced unpleasant effect of the drug and 32.13% patients were non-compliant to treatment due to personal inconvenience such as the necessity to work for livelihood. All the study subjects (100%) were found to be defaulters who had more than one kilometer of distance of their house to the nearest DOTS center. Hence, patient compliance can be improved if the service of treatment is provided nearer to the patient's house [Table 3].

Table 2.

Distribution of clinico-social pattern of the study participants

Table 3.

Distribution of the determinants of the treatment adherence and outcome

DISCUSSION

The findings of the present study show that 90.76% of the study population was within the age group of 15-55 years consistent with previous studies.[11] The persons of this age group are economically productive age group of the society. Experts in this field have observed that poverty and inequality were very closely linked and there is a great health challenge in poor and socially excluded groups. The reason of more TB infection in females of Muslim community may be due to poor economic condition as well as gender neglect. Moreover, the females are more exposed to the indoor air pollution compared with the males due to the use of biomass fuel in cooking, which probably increased risk of TB. Moreover inequities in access to care may reflect underlying epidemiological differences in TB between men and women.[12,13,14] Further, the prevalence of TB is inversely proportional to standard of living index.[12,15] Interestingly 83% of the study population experienced only cough for more than 3 weeks, 15% patients had symptoms of Cough and Fever while 2% patients experienced only fever. Studies conducted by NTI, TRC and Uplekar in Pune have shown that more than 80% of the population, afflicted with a cough for 3 weeks or more, approaches a health facility seeking relief from their symptoms.[16,17,18] Nearly 40.74% of the study population had a habit of smoking only, whereas 9.26% and 1.85% were having habits of chewing tobacco and smoking with alcohol consumption respectively. Consistent with our results previous studies have shown that smoking and chewing tobacco increases the risk of asthma and TB.[19,20]

Passive smoking and biomass fuel combustion creating indoor air pollution also increases TB risk, especially among those at high risk for exposure to TB,[21] which is consistent with previous reports attributing 53% of the prevalence of active TB to cooking smoke.[22] 35% of the study population had a history of contact with previously diagnosed pulmonary TB, which is again consistent with previous reports.[23] Surprisingly and contrary to the Revised National TB Control Program, 56% of the study population had their Chest X-ray conducted before going for Sputum Examination, on the other hand the remaining 44% had their sputum examination first in the process of diagnosis of TB.

The findings of the study showed that 92.6% of the patients had not defaulted, whereas only 7.4% were found to be defaulters. The main risk factors for irregular treatment observed were long distance from the treatment center, unpleasant drug effects and personal inconvenience like the necessity to work for livelihood.[24] Furthermore insufficient knowledge and individual cost during treatment were found to be the main obstacles to compliance among men (poor patient compliance) while sensitivity to interaction with health staff and stigma in society (poor health staff and system compliance) were reported as the main obstacles among women.[25]

Majority of patients gave multiple reasons for default. The DOT providers attributed the defaults to the drug related problems (34%), migration (31%), relief from symptoms (16%), work related problems (10%), alcohol consumption (21%). However, our study identifies other risk factors for default such as alcoholism (P < 0.001), category of treatment (P < 0.001), smear status, type of disease and inconvenience for DOT.[26] A study from Malaysia also reported similar findings in assessing the extent of treatment compliance in TB treatment.[27]

CONCLUSIONS

More than half of NSP TB cases were observed to be among the illiterate and underprivileged population who need counseling and motivation for initiating early intervention. Moreover, it is clear that defaulters can be reduced if the service of treatment is provided nearer to the patient's house.