Challenges of tuberculosis control in South west Ethiopia: treatment delays, cost, and outcomes Abyot Asres Shetano
Creators: name: Asres, Abyot
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2018

description: Background: Tuberculosis (TB) is among the major public health problems over the world. Thus, global efforts have been designed to combat three distinct, but overlapping humanitarian, public health, and economic burdens posed by the TB illness. Timely case detection and treatment of cases have been a focus and priority in the prevention and control of TB. However, long delays to initiate anti-TB treatment have been reported for which evidences on predictors of the delay and impact of the delayed treatment on outcomes are limited. Elimination of catastrophic costs posed by TB illness to patients and households has taken attention in the latest end TB strategy. On the other hand, evidences on magnitude and drivers of patient cost across continuum of TB care are scarce in Ethiopian setting. Treatment regimens play a vital role in reducing time delays to treatment and cost spent across continuum of TB care, and improving outcomes. Nonetheless, evidences on the interdependence among delays, patient cost of care and outcomes in the era of shortened treatment regimen is scanty in Ethiopian setting. Objectives: The aims of the dissertation were 1) to compare outcomes of six and eight-month TB treatment regimen, 2) to determine time delays to initiate anti-TB treatment and its predictors, 3) to assess pre-and post-diagnosis patient costs for TB care and 4) to examine association between delayed anti-TB treatment initiation and treatment outcome. Methods: A blend of cross-sectional and longitudinal studies were conducted among 735 TB cases on treatment and 790 patient records from 14 public health facilities of Bench Maji, Kaffa and Sheka zones in Southwest Ethiopia. The cases were selected using multistage cluster sampling technique. Both primary and secondary data were gathered and/or extracted using structured questionnaire from January 2015 through June 2016. For comparison of outcomes across the six and eight month regimen, patient clinical profiles and outcomes were extracted from unit TB register of cases registered during 2008 through 2014. Data for the cases on treatment were collected at two points; 1) at enrollment when patients" sociodemographics, careseeking practices, direct and indirect costs of TB care seeking were collected and 2) at the end of treatment when treatment practices, patient cost of TB treatment and outcomes were inquired. The data were entered in to Epi-Data and processed on SPSS version 21 and STATA version 13. Since the cost data were right skewed, analysis was made on natural logarithm and reported in corresponding antilog. Bivariate and multiple logistic, linear, and log-binomial regression models were fitted to identify predictors of delays, cost, and outcome. In all the statistical tests, necessary assumptions were checked and significance judged at p&lt;0.05. x Results: The overall treatment success among cases registered during 2008 through 2014 was 88 % ( 85.3% vs 90.6%, p=0.02 among those treated for eight months with 2ERHZ/6HE and six months with 2ERHZ/4RH regimens, respectively). Thus, 4RH continuation phase treatment adjusted Odds Ratio [aOR=0.55,95% CI;(0.34,0.89)], weight gain at the end of second month treatment [aOR=0.28, 95% CI; (0.11, 0.72)] predicted lower odds of unsuccessful outcome. On the other hand, age [aOR=1.02,95%CI; (1.001,1.022)], rural residence [aOR=2.1,95%CI;(1.18,3.75)] and HIV co-infection [aOR=2.39,95%CI;(1.12,5.07)] independently predicted higher odds of unsuccessful outcome. TB patients had spent a median [inter-quartile range (IQR)] of 55(32-100) days to initiate anti- TB treatment since onset of illness (total delay). Similarly a median (IQR) of 25(15-36) and 22(9-48) days had been elapsed respectively to initiate care seeking (patient delay) and anti-TB treatment since first consultation (provider delay). Thus 54.6% of the total delay was attributed to provider (health system) and the rest to the patient. Prior self-treatment (aOR: 1.72, 95% confidence interval [CI]:1.07-2.75), HIV co-infection (aOR: 1.80, 95% CI: 1.05-3.10) and extra pulmonary TB (aOR: 1.54, 95% CI: 1.03-2.29) independently predicted higher odds of patient delay. On the other hand, initial visits to health posts or private clinics (aOR: 1.42, 95% CI: 1.01, 2.0) and delayed to seek care (aOR: 1.81, 95% CI: 1.33-2.50) significantly predicted higher odds of provider delay. Since onset of illness, TB patients totally incurred mean [(standard deviation (+SD)] of US$244.71(+0.1) for care seeking and treatment. Thus mean (+SD) US$108.0(+0.1) and US$117.0(+0.1) were respectively incurred during pre-diagnosis and post-diagnosis periods. Mean (+SD) out of pocket patient expenditures during pre-and post-diagnosis were US$21.46(0.16) and US$43.80(+0.1) respectively. Total indirect and pre-diagnosis costs constitute 70.6% and 53.6% of the total cost respectively. Patient delay (adjusted coefficient (βadj)= 0.004, p&lt;0.001), provider delay (βadj =0.004,p&lt;0.001), number of visited healthcare facilities (βadj =0.17,p&lt;0.001) and diagnosis at private facilities (βadj=0.16,p=0.02) independently predicted increased pre-diagnosis cost. Similarly, rural residence (βadj=0.27,p&lt;0.001), hospitalization (βadj=0.91,p&lt;0.001), patient delay (βadj=0.002,p&lt;0.001) and provider delay (βadj =0.002,p&lt;0.001) predicted increased post-diagnosis costs. The overall treatment success among the prospectively enrolled cases was 89.7% (86.7% vs. 92.6%, p=0.01) respectively among those initiated anti-TB treatment beyond and within 55days xi of onset of illness). Accordingly, treatment initiation beyond 55days of onset [Adjusted Relative Risk (aRR)=1.92, 95%CI:1.30, 2.81),treatment center being hospital (aRR=3.73, 95%CI:2.23, 6.25), and HIV co-infection (aRR=2.18, 95%CI: 1.47, 3.25) independently predicted higher risk of unsuccessful treatment outcome. In contrast, weight gain at the end of second month treatment (aRR=0.40, 95%CI: 0.19, 0.83) predicted lower risk of unsuccessful outcome. Conclusions: The switch of continuation phase TB treatment regimen from 6EH to 4RH has brought significantly higher treatment success that verified applicability of the regimen change in resource constrained and high burden countries. TB cases in the study area elapsed too long time to initiate care seeking and treatment. The delays are attributed to the patient, disease and health system related factors. Throughout the care seeking and treatment pathways, TB cases incurred substantial direct and indirect cost for TB care despite the "free TB service". The delay to initiate anti-TB treatment was significantly associated with increased patient costs and risk of unsuccessful outcome. Patient and health system attributes predicted both costs incurred across continuum of TB care and treatment outcome. Recommendations Promotion of early care seeking for TB through community level awareness creation; involving both formal and informal providers can minimize patient delays. Moreover, improving diagnostic and case-holding efficiencies of both private and public healthcare facilities can reduce delays to treatment and risk of unfavorable outcomes. On the other hand, adoption of patient centered TB care, reimbursement mechanisms of costs and scale up of the national community and social insurance schemes to the study area can reduce the financial burden on patients. Finally, further studies are required to explore reasons for patient and provider delays using qualitative designs, costs of TB care, and its impacts on household and health system.