Abstract
BackgroundTuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally. Addressing the social determinants of TB is crucial to ending TB. This study sought to understand the extent and ways in which socio-economic factors affect TB treatment outcomes in Karamoja.MethodsWe conducted a convergent parallel mixed methods study in 10 TB Diagnostic and Treatment Units. The study enrolled former TB patients diagnosed with drug-susceptible TB between April 2018 and March 2019. Unit TB and laboratory registers were reviewed to identify pre-treatment losses to follow-up. Four focus group discussions with former TB patients and 18 key informant interviews with healthcare workers were conducted. Principle component analysis was used to generate wealth quintiles that were compared to treatment outcomes using the proportion test. The association between sociodemographic characteristics and TB treatment outcomes was evaluated using the chi-square test and multiple logistic regression.ResultsA total of 313 participants were randomly selected from 1184 former TB patients recorded in the unit TB registers. Of these, 264 were contacted in the community and consented to join the study: 57% were male and 156 (59.1%) participants had unsuccessful treatment outcomes. The wealthiest quintile had a 58% reduction in the risk of having an unsuccessful treatment outcome (adj OR = 0.42, 95% CI 0.18–0.99, p = 0.047). People who were employed in the informal sector (adj OR = 4.71, 95% CI 1.18–18.89, p = 0.029) and children under the age of 15 years who were not in school or employed (adj OR = 2.71, 95% CI 1.11–6.62, p = 0.029) had significantly higher odds of unsuccessful treatment outcome. Analysis of the pre-treatment loss to follow-up showed that 17.2% of patients with pulmonary bacteriologically confirmed TB did not initiate treatment with a higher proportion among females (21.7%) than males (13.5%). Inadequate food, belonging to migratory communities, stigma, lack of social protection, drug stock-outs and transport challenges affected TB treatment outcomes.ConclusionsThis study confirmed that low socio-economic status is associated with poor TB treatment outcomes emphasizing the need for multi- and cross-sectoral approaches and socio-economic enablers to optimise TB care.
Highlights
Tuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally
Focus group discussions (FGDs) with former TB patients and key informant interviews (KII) with healthcare personnel involved in TB care were conducted to capture patient experiences and health system factors that could affect TB treatment outcomes
Mixed methods were selected to extend the breadth of inquiry on the impact of socioeconomic factors on TB treatment outcomes: quantitative methods were used to establish the magnitude of the association between socio-economic factors and TB treatment outcomes while FGDs and KIIs were used to identify perceptions on how conditions of daily life and healthcare system factors acted as barriers or motivators during TB treatment
Summary
Tuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally. The epidemiological impact of available therapeutic and preventive strategies on pertinent TB indicators has been slow, resulting in the growing recognition of the role of social determinants of health at an individual and societal level on strategies to end TB as a public health problem [3,4,5,6]. Social status and daily living conditions modify several risk factors over time and influence access to resources leading to differential exposure, differential vulnerability to disease-causing and/or modifying agents and differential consequences of ill health [13, 14]
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