Context: India has the highest tuberculosis (TB) burden in the world in terms of the absolute number of cases that occur each year. The directly observed treatment, short-course (DOTS) strategy is the most systematic and cost-effective approach to controlling this disease. Furthermore, understanding the specific reasons for treatment outcomes is important for the improvement of treatment systems. Aims: This study aimed to determine certain sociodemographic factors that contribute to TB treatment outcome. Settings and Design: A prospective study was conducted among 302 TB patients at four designated microscopy centers (DMCs) of Aligarh District, Uttar Pradesh from April 2012 to June 2013. Materials and Methods: Study subjects were followed up from the initiation to the end of treatment. Baseline data were collected using a pretested questionnaire. The subjects were interviewed at least 3 times each during their treatment. Outcomes were considered as per the Revised National Tuberculosis Control Programme (RNTCP) standard definition. “Cured” and “treatment completed” were considered good outcomes, while “default,” “failure,” and “death” were considered poor outcomes. Statistical Analysis Used: Data were analyzed in SPSS 17 using the chi-square test and univariate logistic regression to determine the association. The odds ratio (OR) and 95% confidence interval (CI) were calculated in logistic regression. Results: The majority of the subjects were male (72.2%) and in the age group of 15-30 years. Among the subjects, 53% resided in urban areas; 63.6% were literate; and 45% had a high standard of living index (SLI). Age group, literacy status, and SLI were found to be significantly associated with outcome (P < 0.05). On logistic regression, the 31-45-years age group, literacy, and high SLI were found to be significantly associated with good outcome.
Keywords: Aligarh, directly observed treatment, short-course (DOTS), outcome, sociodemographic factor
|How to cite this article:
Kanungo S, Khan Z, Ansari MA, Abedi AJ. Role of sociodemographic factors in tuberculosis treatment outcome: A prospective study in Aligarh, Uttar Pradesh. Ann Trop Med Public Health 2015;8:55-9
|How to cite this URL:
Kanungo S, Khan Z, Ansari MA, Abedi AJ. Role of sociodemographic factors in tuberculosis treatment outcome: A prospective study in Aligarh, Uttar Pradesh. Ann Trop Med Public Health [serial online] 2015 [cited 2020 Nov 26];8:55-9. Available from: https://www.atmph.org/text.asp?2015/8/3/55/157629
India has the highest tuberculosis (TB) burden in the world in terms of the absolute number of cases that occur each year. It alone accounted for one-fourth of the estimated global incidence in 2010.  Every year, around 1.8 million new cases are reported in India, of which 0.8 million are infectious. It is estimated that two individuals die of it in our country every 3 min.  Besides the disease burden, TB also causes enormous socioeconomic devastation in India. TB primarily affects people in their most productive years of life, with important socioeconomic consequences for the household. The disease is more common among the poorest and marginalized sections of the community. 
Recognizing that the TB epidemic was out of control, in 1997 the Revised National Tuberculosis Control Programme (RNTCP) was developed by the formulation and adoption of the internationally recommended directly observed treatment, short-course (DOTS) strategy as the most systematic and cost-effective approach to revitalize the TB control program in India. The goal is to achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear-positive) cases and to achieve and maintain detection of at least 70% of estimated new sputum-positive cases in the population.  TB treatment outcomes are influenced not only by bacterial characteristics, patient characteristics, and patient behavior, but also by the quality of health care. Monitoring the outcome of treatment is essential in order to evaluate the effectiveness of the DOTS program.
Furthermore, understanding the specific reasons for unsuccessful outcomes is important for the improvement of treatment systems.  These factors are absolutely critical to cure the patients, prevent further transmission, and stop the emergence of resistance cases. Therefore, this present study was planned to find out the effects of sociodemographic factors on TB treatment outcome in patients under DOTS in Aligarh District, Uttar Pradesh.
|Materials and Methods|
This was a prospective study conducted among 302 TB patients under DOTS in Aligarh District during the period April 2012-June 2013. The 15-month period allowed the patients placed in any category of treatment, including those whose intensive phase was extended for 1 month, to complete the entire period of treatment, thus providing the researchers with sufficient time for the collection and collation of information. The RNTCP covered 100% of the population of the district through seven TB units (TUs; two urban and five rural) and 32 designated microscopy centers (DMCs). Multistage random sampling was done. In the first stage, four TUs were selected randomly. Then four DMCs were selected randomly, one from each selected TU. J.N. Medical College, Jawan, Jeevan Jyoti Hospital, and Harduaganj were the selected DMCs, and all the patients registered at these centers were included in this study. Considering the inclusion criteria of being >15 years of age and registered between April 2012 and June 2012 (2nd quarter), a total of 302 TB patients were included in our study.
All four selected DMCs were visited and eligible patients were registered for the study. All selected centers were visited by rotation on Mondays, Wednesdays, and Fridays, as these were the DOTS days in Aligarh District. Each eligible patient was interviewed and examined at least three times:
- Once within the first week of initiation of treatment,
- Subsequent follow-up at the end of the intensive phase, and
- At the end of the treatment.
Interviews were conducted after verbal consent was taken and rapport built with the patients. Interviews of patients that could not be performed at the DMCs were conducted at the DOTS centers. The date of the interview was discussed with the RNTCP staff and DOTS providers prior to the interview. A pretested pro forma, modified suitably as per the RNTCP quarterly treatment outcome-monitoring pro forma, was used for interviewing the patients; it consisted of questions regarding the baseline sociodemographic profile of each patient, including the variables of age, sex, religion, marital status, education, occupation, address, and standard of living index (SLI). 
For any patient who successfully completed their treatment and was declared “cured” or “treatment completed,” it was considered as good outcome. For those patients whose treatment ended with “death,” “default,” or “treatment failure,” they were considered as poor outcome. 
The study was approved by the Institute Ethical Committee of J.N. Medical College, Aligarh Muslim University (AMU), Aligarh. Permission from the college and written consent from the district program authority were taken. Informed consent was taken from all participants of the study, including the patients and their care providers.
Data management and processing
Statistical Product and Service Solutions (IBM SPSS Statistics) version 20 was used to find out the relation between sociodemographic factors and treatment outcome. IBM SPSS Statistics was used by the authors through the academic research facilities provided by the AMU for use on the campus. For further details, the Computer Cell, AMU may be contacted.
The maximum number of cases (43.4%) was in the age group of 15-30 years, and the number declined with increasing age. The mean age was calculated to be 36.9 years. Our results showed a higher case detection rate in males (72.2%) than in females (27.8%), with a male-to-female ratio of 2.6:1. Of the patients, 53% were residing in urban areas. The majority (64.2%) of the study cohort belonged to the Hindu religion. In addition, 36.4% of the patients were found to be at the illiterate level in our study [Table 1]. Our results also revealed that 24.2% of the study population was comprised of unskilled workers, while 19.8% of the study population were unemployed. Professionals constituted only 3.6% of the study population, and 5.8% had retired from their jobs. As far as the SLI was concerned, only 21.5% of the study population had low SLI, while 45.4% had high SLI [Table 2].
|Table 1: Distribution of treatment outcomes among sociodemographic factors (age group, sex, area, and religion) [n = 302]
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|Table 2: Distribution of treatment outcomes among sociodemographic factors (education, occupation, and SLI) [n = 302]
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It is evident that the majority of cases (80.8%) in our study suffered from pulmonary TB, while the rest (19.2%) had extrapulmonary TB. Among the cases, 86.4% were treated as new patients and 13.6% were retreatment patients. Retreatment cases included relapse, default, failure, and others.
Outcome was categorized as good (“cured” and “treatment completed”) and poor (“default,” “death,” and “failure”) in the present study. Good outcome was found in 262 (86.8%) subjects within our study cohort [Figure 1].
|Figure 1: Distribution of treatment outcome of overall study population (n = 302) (original)
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Young age was significantly associated with good treatment outcome, with the odds ratio (OR) 3.63 [95% confidence interval (CI) 1.19-11.0] and 3.41 (95% CI 1.05-11.06) for the age groups 15-30 and 31-45 years, respectively (P < 0.05). Among the good or favorable outcome results, 71% were in males and 29% (the rest) in females. As far as poor or unfavorable outcome was concerned, 80% was in males and 20% (the rest) in females. Although good outcome seems linked to greater likelihood in females in our study, this association was found to be statistically insignificant. Among the subjects with good outcome, 54.2% belonged to urban areas, while 45.8% were from rural areas. But this association was not proved to be statistically significant (P > 0.05). Of the patients who completed their treatment with good outcome, 65.3% were Hindus and 34% were Muslims, while their share in poor outcome was 57.5% and 42.5%, respectively. Analyzing individual religions separately, good outcome was more common in Hindu subjects than in Muslim subjects, but this was not statistically significant (P > 0.05) [Table 1] and [Table 3].
|Table 3: Univariate logistic regression showing association of determinants with good outcome
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Of the patients with good outcome, the majority (67.6%) were literate and the literacy status was found to be statistically significant with treatment outcome (P < 0.05). Again, on univariate logistic regression, literacy was found to be a significant predictor of good outcome, with an OR of 3.47 with 95% CI 1.74-6.9 (P < 0.001). No significant association was observed between any occupational group and treatment outcome in the present study.
Most of the patients (48.4%) whose treatment was good had a high SLI. This association between SLI and treatment outcome was found to be statistically significant (P < 0.05). Again, on univariate logistic regression, high SLI was found to be a significant predictor of good outcome in comparison to low SLI, with the OR of 3.48 (95% CI 1.45-8.35) [Table 2] and [Table 3].
Ahmad and Velhal (2013) and da Silva Garrido et al. (2012) reported age to be a significant factor associated with treatment outcome. , Ditah et al. (2008) also found older age to be a significant risk factor for unsuccessful outcome.  Our study corroborates these findings. Decline of immunity with age might be the reason. However, Ahmed et al. (2009) found no significant association between age and treatment outcome in Karnataka. 
Getahun et al. (2013) found that treatment outcome was not significantly affected by gender.  Boateng et al. (2010) found that males had defaulted significantly higher than females.  Ahmad and Velhal (2013) found that the cure rate was significantly higher in females (53%) compared to males (39.35%), which is well supported by Mukherjee et al. (2012). , The treatment completion rate was also higher in females in both the studies. Thus, despite facing obstacles such as stigma, negligence, poverty, and low case detection rate, better results were seen in females. In the present study, we also observed better results in females, though they were not statistically significant. Our findings are in accordance with Joseph et al. (2011), who found no association between place of residence and treatment outcome in TB patients. 
Mukhopadhyaya et al. (2010) found that urban residents were more likely to end in failure cases than rural patients. But their study was conducted only on retreatment patients.  Our result might be attributed to the equality in RNTCP services in both the urban and rural areas of the district. The study also found no association between religion and cure of TB. 
Our findings substantiate the findings of some other studies that also reported a significant association between treatment outcome and literacy status. ,, Mateus-Solarte and Carvajal-Barona (2008) observed no association between occupation and completion of treatment (good outcome) in the line of findings of the present study.  Ahmed and Velhal (2013) found that the cure rate was high among professionals and businessmen.  There were more defaulters among laborers compared to professionals and businessmen. Mishra et al. (2005) found that unemployed persons or persons in low-status occupations had a statistically significant higher risk of nonadherence to treatment. No significant association was observed between any occupational group and treatment outcome in the present study. 
Johansson et al. (1996) noted that a patient’s economic situation is an important determinant in treatment compliance and cure.  Belo et al. (2011) revealed that unsuccessful treatment was associated with socioeconomic status.  de Albuquerque et al. (2007) revealed that low income was one of the significant predictors of unsuccessful treatment outcome.  Our findings are in concordance with the study by Belo et al., (2011) who reported a higher risk of unsuccessful outcome in lower socioeconomic status patients with OR of 1.6 (1.02-2.4). 
|Conclusion and Recommendation|
Our study also tried to find out the predictors of treatment outcome. Sex, religion, place of residence, and occupation was not found to have any bearing on the outcome of treatment. This indicates that the program has effectively reached out to all irrespective of caste, creed, and religion. The main aim of RNTCP is to bring the TB program from the district headquarter to the village level (“TB ka ilaaj aap ke haath aap ke paas,” or “TB cure is in your hands and close by”). This has been very well achieved in Aligarh District, as the treatment outcome was found to be not associated with place of residence. Similarly, nonassociation of the treatment outcome with sex was also a good sign of the program’s progress toward equity. Our study showed the significant association of treatment outcome with literacy and SLI. Patient-provider interaction can reduce the barriers of illiteracy and social class. Service providers’ skills should be developed in the realm of interpersonal communication so that they can give proper counseling to the patients.
Limitations of the study
In order to economize the resources and keeping operational feasibility in mind, the study could not be conducted in all the seven TUs of the district. As this study was concerned with a cohort of only one quarter of a year, we could not find the annual case detection rate, which was also a part of evaluation. In addition, both pulmonary and extrapulmonary TB patients were considered together as subjects for this study.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]