Beruflich Dokumente
Kultur Dokumente
Abstract Resumen
1 Centro de Estudios de This study aimed to identify the individual and El objetivo fue identificar los determinantes in-
Estado y Sociedad, Buenos
Aires, Argentina.
environmental determinants of nonadherence dividuales y de rea de la no adherencia al tra-
2 rea de Relaciones to tuberculosis (TB) treatment in selected dis- tamiento de la tuberculosis (TB) en municipios
Internacionales, Facultad tricts in the Buenos Aires Metropolitan Area, in de Buenos Aires, Argentina. Se realiz un estudio
Latinoamericana de Ciencias
Sociales, Buenos Aires,
Argentina. We conducted a cross-sectional study transversal con un modelo jerarquizado. El an-
Argentina. using a hierarchical model. Using primary and lisis se llev a cabo mediante regresin logstica
3 Consejo Nacional de
secondary data, logistic regression was per- mltiple en dos niveles, en base a datos prima-
Investigaciones Cientficas
y Tcnicas, Buenos Aires, formed to analyze two types of determinants. rios y secundarios. Los varones tuvieron mayor
Argentina. The likelihood of nonadherence to treatment riesgo de no adherencia al tratamiento. La fal-
4 Instituto de Medicina Social,
was greatest among male patients. The follow- ta de provisin de agua en el hogar aument
Universidade do Estado do
Rio de Janeiro, Rio de Janeiro, ing factors led to a greater likelihood of nonad- el riesgo de no adherencia. En aquellos hogares
Brasil. herence to treatment: patients living in a home cuyo jefe de familia no tena cobertura de salud
without running water; head of household with- tambin el riesgo de no adherencia fue mayor, al
Correspondence
M. B. Herrero out medical insurance; need to use more than igual que en los pacientes que utilizaron ms de
Centro de Estudios de Estado one means of transport to reach the health cen- un medio de transporte para llegar al centro de
y Sociedad.
ter; place of residence in an area with a high pro- salud. En las reas con mayor proporcin de ho-
Sanchez de Bustamante 27,
Buenos Aires 1173, Argentina. portion of households connected to the natural gares con red de gas natural, mayor proporcin
mbelen.herrero@gmail.com gas network; place of residence in an area where de hogares con necesidades bsicas instisfechas
a large proportion of families fall below the min- por la capacidad de subsistencia y mayor pro-
imum threshold of subsistence capacity; place of porcin de hogares que no tenan inodoros fue
residence in an area where a high proportion of mayor el riesgo de no adherencia. Se concluye
households do not have flushing toilets and ba- que los factores sociales y econmicos tienen in-
sic sanitation. Our results show that social and fluencia sobre la adherencia al tratamiento, tan-
economic factors related to both individual to a nivel individual, como de rea.
and environmental characteristics influence
adherence to TB treatment. Tuberculosis; Cumplimiento de la Medicacin;
Factores Epidemiolgicos; Estudios
Tuberculosis; Medication Adherence; Transversales
Epidemiologic Factors; Cross-sectional Studies
rupted treatment for 60 consecutive days or more tients and heads of households, housing, disease,
were classified as nonadherent patients 21,22. treatment, and access to health services. The sec-
Adherent patients were all eligible patients who ond level of analysis included information on so-
completed the stipulated treatment 22. ciodemographic and socioeconomic character-
istics relating to the place of residence of patients
Design based on the census tracts of the 2001 National
Population, Household and Housing Census. One
The first level of analysis personal character- of the indicators used was the unsatisfied basic
istics used primary data obtained from the needs (UBN), a proxy indicator of poverty based
abovementioned sample. The study protocol (in- upon the threshold of subsistence capacity that
cluding the questionnaire) was approved by the considers the ratio between the number of em-
Ethics Committees of all participating hospitals. ployed family members and the total number of
After signing an informed consent form, patients family members, and the level of education of
were interviewed using a structured question- the head of the household. The characteristics
naire. At the end of the interview, advice was of the place of residence for each sample mem-
provided to nonadherent patients about the im- ber were defined according to the census tract of
portance of completing treatment. The question- the patients place of residence and expressed as
naire was pilot-tested with 10 patients (not in- a percentage or divided into subsets (lower and
cluded in the study sample) from the study area. upper), depending on the type of characteristic.
The second level of analysis sociodemo- The data was analyzed using the Stata 10.0
graphic and socioeconomic characteristics of the (StataCorp., Colege Station, USA) software pack-
place of residence of patients used secondary age. First, an exploratory bivariate analysis of
data from the 2001 National Population, House- both levels of characteristics was performed to
hold and Housing Census (anonymous census assess sample distribution. Multiple regression
data obtained by electronic means from the In- analysis was then performed with variables that
stituto Nacional de Estadsticas y Censos. http:// showed a significant level of correlation (p < 0.2)
www.indec.gov.ar/, accessed on 27/Sep/2015). and those that were deemed essential for the ex-
planatory model. Those variables that showed a
Statistical analysis statistically significant association (p < 0.05) were
retained. Finally, a hierarchical analysis was per-
In contrast to prediction, the choice of the vari- formed for both levels and the variables associ-
ables to be included in a statistical model is not ated with the outcome with a significance level of
based on a purely statistical association. The 0.05 were preserved. The dependent variable was
factors chosen by this study were chosen based noncompliance.
on a conceptual framework which analyzed the
hierarchical relationships the factors that influ-
ence adherence. As Victora et al. 23 note, certain Results
factors may have an indirect influence on adher-
ence and are therefore called proximal or distal The final sample comprised 123 patients from
determinants: the individual and environmental an initial total of 193 eligible patients (64%), of
(place of residence) determinants in the present which 38 were nonadherent and 85 adherent.
study. Distal factors are more likely to act through Forty (51%) nonadherent patients and 30 (26%)
a number of inter-related proximate determi- adherent patients were excluded because they
nants (the individual determinants in the pres- could not be contacted either due to death, wrong
ent study). address, or because the patient had moved to an-
We therefore subdivided the proximate and other district.
distal determinants into hierarchically interre- Tables 1 and 2 show the main sociodemo-
lated or parallel groups. As Victora et al. 23 note, graphic and socioeconomic characteristics of the
studies commonly fail to adequately adjust en- patients and their place of residence.
vironmental (distal) factors related to place of Table 3 shows the results of the bivariate and
residence to individual (proximal) factors, thus multivariate analyses for the first level of analysis
reducing or eliminating the effects of the for- (personal characteristics). The latter showed that
mer. Therefore, knowledge of the environmental male patients were three times more likely to not
(place of residence) and individual determinants adhere to treatment (OR = 2.91; 95%CI: 1.1-8.3).
of nonadherence is essential to build a conceptual Patients without running water in their homes
framework. In this study, the first level of analysis were five times more likely to interrupt treatment
(personal characteristics) included information (OR = 4.74; 95%CI: 1.5-15.1), while those from
on the sociodemographic characteristics of pa- households whose heads did not have health in-
Table 1
Characteristics included in the first level of analysis (personal characteristics), adherent and nonadherent patients. Sixth Health
Region (HRVI), Buenos Aires Metropolitan Area, Argentina.
Sex
Female 43 50.6 12 31.6 55 44.7
Male 42 49.4 26 68.4 68 55.3
Total 85 100.0 38 100.0 123 100.0
Residence
Lives with somebody 78 91.8 32 84.2 110 89.4
Lives alone 7 8.2 6 15.8 13 10.6
Total 85 100.0 38 100.0 123 100.0
Health insurance
Yes 19 22.4 6 15.8 25 20.3
No 66 77.7 32 84.2 98 79.7
Total 85 100.0 38 100.0 123 100.0
Work situation
Working 58 68.2 25 65.8 83 67.5
Not working 27 31.8 13 34.2 40 32.5
Total 85 100.0 38 100.0 123 100.0
Water supply
House connected 68 81.0 22 57.9 90 73.8
Outside/On-plot 16 19.1 16 42.1 32 26.2
Total 84 100.0 38 100.0 122 * 100.0
Sanitation services
Flushing toilet 57 67.1 21 55.3 78 63.4
Nonflushing toilet 26 30.6 14 36.8 40 32.5
Pit latrine 2 2.4 3 7.9 5 4.1
Total 85 100.0 38 100.0 123 100.0
Head of household health insurance
Yes 28 32.9 6 15.8 34 27.6
No 57 67.1 32 84.2 89 72.4
Total 85 100.0 38 100.0 123 100.0
Work status of head of household
Employed 72 85.7 30 79.0 102 83.6
Unemployed/Inactive 12 14.3 8 21.1 20 16.4
Total 84 100.0 38 100.0 122 * 100.0
Household income level
Over US$245 23 27.7 8 21.1 31 25.6
Between US$124 and US$245 44 53.0 13 34.2 57 47.1
Up to US$123 16 19.3 17 44.7 33 27.3
Total 83 100.0 38 100.0 121 ** 100.0
Type of health facility where treatment was provided
Primary Health Centre 33 38.8 7 18.4 40 32.5
Referral hospital 52 61.2 31 81.6 83 67.5
Total 85 100.0 38 100.0 123 100.0
Type health facility where control visits were carried out
Primary Health Centre/Other 33 38.8 6 15.8 39 31.7
Referral hospital 52 61.2 32 84.2 84 68.3
Total 85 100.0 38 100.0 123 100.0
(continues)
Table 1 (continued)
TB: tuberculosis.
* 1 missing;
** 2 missings;
*** 3 missings;
# 13 non-apllicable.
surance were six times more likely to not adhere and those who were not granted leave of absence
(OR = 5.74; 95%CI: 1.5-21.9). Patients receiving to carry out checkups were almost eight times
treatment at referral hospitals were five times more likely to not adhere (OR = 7.78; 95%CI: 1.2-
more likely than primary health care center pa- 51.9). Finally, patients who had to use more than
tients to interrupt treatment (OR = 4.54; 95%CI: one means of transport were almost five times
1.2-16.8). Patients who did not receive sufficient more likely not to adhere to treatment than those
information were 10 times more likely to not ad- using only one means (OR = 4.7; 95%CI: 1.3-16.3).
here to treatment (OR = 10.36; 95%CI: 1.6-68.3),
Table 2
Characteristics included in the second level of analysis (environmental characteristics related to place of residence), adherent and nonadherent patients. Sixth
Health Region (HRVI), Buenos Aires Metropolitan Area, Argentina.
Table 4 shows the results of the bivariate and the likelihood of nonadherence was also higher
multivariate analyses for the second level of anal- in areas with a high proportion of self-employed
ysis (place of residence). The latter showed that workers (OR = 2.84; 95%CI: 1.1-7.7).
nonadherence was more likely in areas where a The results of the hierarchical analysis (Ta-
large proportion of households were connected ble 5) show that male patients are three times
to the natural gas network (OR = 0.25; 95%CI: more likely to not adhere to treatment (OR =
0.1-0.7). Also, patients living in areas with a large 3.53; 95%CI: 1.23-10.11). Moreover, nonadher-
proportion of households under the subsistence ence was four times more likely in households
capacity threshold were three times more like- without running water than in households with
ly to not adhere to treatment (OR = 3.4; 95%CI: this service (OR = 4.18; 95%CI: 1.29-13. 47). The
1.4-8.5). The lack of a flushing toilet and basic likelihood of nonadherence was six times greater
sanitation led to a three-fold increase in the like- in households whose head did not have health
lihood of nonadherence (OR = 3.39; 95%CI: 1.2- insurance (OR = 5.47; 95%CI: 1.36-21.93). Ad-
9.4). On the other hand, likelihood was lower in ditionally, patients who had to use more than
areas where a large proportion of the population one means of transport were almost seven
was inactive (OR = 0.3; 95%CI: 0.1-0,8). Finally, times more likely to not adhere to treatment
Table 3
Bivariate and multivariate analysis of factors associated with nonadherence to tuberculosis (TB) treatment at the first level of analysis (personal characteristics),
adherent and nonadherent patients. Sixth Health Region (HRVI), Buenos Aires Metropolitan Area, Argentina.
Sex
Female 31.6 1.00 1.00
Male 68.4 2.20 1.0-5.0 0.053 2.91 1.1-8.3 0.047
Water supply
House connected 57.9 1.00 1.00
Outside/on-plot 42.1 3.10 1.3-7.2 0.009 4.74 1.5-15.1 0.009
Sanitation services
Flushing toilet 55.3
Nonflushing toilet 36.8
Pit latrine 7.9 1.70 0.9-3.2 0.122
Head of household health insurance
Yes 15.8 1.00 1.0 1.00
No 84.2 2.60 0.9-6.9 0.055 5.74 1.5-21.9 0.011
Household income level
Over US$245 21.1 1.00
Between US$124 and U$245 34.2
Up to US$123 44.7 1.90 1.1-3.3 0.027
Type of health facility where treatment was provided
Primary Health Centre 18.4 1.00
Referral hospital 81.6 2.80 1.1-7.1 0.029
Type of health facility where control visits were carried out
Primary Health Centre/Other 15.8 1.00 1.00
Referral hospital 84.2 3.40 1.3-9.0 0.014 4.54 1.2-16.8 0.023
Received sufficient information about the disease and treatment
Yes 86.8 1.00 1.00
No 13.2 6.30 1.2-3.4 0.033 10.36 1.6-68.3 0.015
Was granted leave of absence from work to visit the health center
Yes 76.3 1.00 1.00
No 23.7 6.30 1.8-2.2 0.004 7.78 1.2-51.9 0.034
Difficulties transport costs
No 32.4 1.00
Yes 67.6 2.60 1.2-5.9 0.022
Difficulties transport time
No 64.9 1.00
Yes 35.1 1.96 0.8-4.6 0.123
Number of means of transport used to visit the health center
One 70.6 1.00 1.00
More than one 29.4 2.22 0.9-5.8 0.104 4.70 1.3-16.3 0.017
TB/HIV co-infection
No 92.1 1.00
Yes 7.9 3.60 0.6-2.2 0.175
Adequate knowledge of completion of treatment
Yes 23.7 1.00
No 76.3 1.85 0.8-4.4 0.165
Table 4
Bivariate and multivariate analysis of factors associated with nonadherence to tuberculosis (TB) treatment at the second level
of analysis (environmental characteristics related to place of residence), adherent and nonadherent patients. Sixth Health
Region (HRVI), Buenos Aires Metropolitan Area, Argentina.
Table 5
Results of the final hierarchical model showing factors influencing nonadherence to tuberculosis (TB) treatment. Sixth Health
Region (HRVI), Buenos Aires Metropolitan Area, Argentina.
Sex
Female 31.6 1.00
Male 68.4 3.53 1.2-10.1 0.018
Water supply
House connected 57.9 1.00
Outside/on-plot 42.1 4.18 1.3-13.5 0.016
Head of household health insurance
Yes 15.8 1.00
No 84.2 5.47 1.4-21.9 0.016
Number of means of transport
One 70.6 1.00
More than one 29.4 6.47 1.7-24.6 0.006
Natural gas network
In good condition 73.7 1.00
In bad condition 26.3 0.18 0.1-0.6 0.005
Subsistence capacity
Below threshold 42.1 1.00
Above threshold 57.9 3.04 1.1-8.6 0.035
Flushing toilet and basic sanitation
Upper subset 29.0 1.00
Lower subset 71.1 5.08 1.5-17.1 0.009
of treatment interruption among males 7,25, such fact that treatment is free of charge 6,7,8,9,10,27,28.
as alcohol and drug abuse, and smoking. These studies show that low socioeconomic sta-
Our results show that the likelihood of non- tus negatively influences adherence due to the
adherence is greater among patients living in direct and indirect costs of treatment, such as
households whose heads did not have medical transport, additional medication, and even the
insurance. This concurs with findings of other time spent on treatment (i.e., time spent away
studies that showed an increased likelihood of from work) 6,7,28. Our study suggests that other
nonadherence among patients without health factors also affect adherence among patients
insurance, even when treatment was free of with low socioeconomic status. Patients who
charge 24,26. These studies suggest that the loss have to use more than one means of transport to
of income due to health problems is a significant visit the health center were five times more likely
factor affecting treatment adherence, particu- to not adhere than patients who only use one
larly in the case of workers with no health insur- means. Several studies show that high transport
ance or social protection who therefore have no costs reduce the patients capacity to continue
income when they stop working (in contrast to treatment, particularly those with a low socio-
salaried workers) 24,26. economic status 6,7,11. In our study, household
Another factor associated with nonadher- income was lower among nonadherent patients
ence to treatment is the lack of running water in than in adherent patients. However, this vari-
the home, which is an indicator of structural pov- able was excluded from the final model due to
erty in Argentina (Instituto Nacional de Estadsti- the small sample size. Further research is needed
cas y Censos. http://www.indec.gov.ar/, accessed to analyze the influence of indirect costs on pa-
on 27/Sep/2015). Various studies worldwide have tients capacity to adhere to treatment, particu-
highlighted the association between nonadher- larly in high poverty contexts.
ence to TB treatment and poverty, despite the
The majority of nonadherent patients in our and nonadherence. Second, the small sample
sample are from families with low socioeconom- size may affect analysis and the generalization
ic status. Our results suggest that the likelihood of results to a larger universe of patients with
of nonadherence is greater among patients living TB, particularly with respect to environmental
in areas where a high proportion of households characteristics. We believe that further research
do not have a flushing toilet or basic sanitation. is needed to assess aspect.
This is one of the indicators of structural poverty However, this study has a number of
in Argentina, and one of the components of the strengths. First, despite losing significance in the
UBN Index. Our results corroborate the findings final model, the bivariate analysis showed a sig-
of other studies that show that health is affected nificant association between nonadherence to
by living conditions, particularly in areas with treatment and a number of individual and envi-
high levels of high poverty and social inequal- ronmental characteristics. This fact shows that
ity 29. Moreover, the risk of treatment dropout nonadherence is socially determined and that,
was higher in areas where a large proportion of at least among this sample, there is a connection
families fall below the minimum threshold of between nonadherence and poor living condi-
subsistence capacity. This is a proxy indicator of tions and poverty in the place of residence. Fur-
household income based on the ratio between ther research is required, not only to gain greater
the number of employed family members and insight into the connection between individual
total number of family members, and the level and environmental characteristics and nonad-
of education of the head of the household 30,31. herence to treatment, but also to assess the rela-
Studies that included level of education as a tive contribution of each factor and determine
variable show that illiterate patients (or patients which factor has the greatest influence: being
who have a low level of education) are generally poor or living in a poor area.
1.3 to 1.7 times more likely to dropout of treat-
ment than patients with a higher level of educa-
tion 27,32,33. A study conducted in Southern India Conclusion
shows that level of education influences patient
health behavior due to its association with low Our findings show that social and economic fac-
income and work status, and low levels of knowl- tors related to both individual and environmen-
edge regarding treatment 34. tal (place of residence) characteristics influence
Our study has certain limitations. First, the adherence to TB treatment. Strategies to reduce
smallest spatial units of collection were the cen- treatment dropout should address the multiplic-
sus tracts determined by the provincial govern- ity of factors that influence adherence and priori-
ment based on convenience, rather than on tize social protection interventions for the most
social criteria 35. Thus, the heterogeneity of the socially and economically vulnerable patients,
shape, area and population size of these tracts including the provision of individual and fam-
(for example, the population of certain census ily support. We also believe that further research
tracts was over 1,500), together with the possibil- into the social determinants of nonadherence to
ity of income variation within each census unit, treatment is essential for tackling the individual
is a limiting factor and may lead to a underes- and environmental factors that lead to nonad-
timation of the relationship between the envi- herence.
ronmental characteristics (place of residence)
Resumo Contributors
O objetivo deste trabalho foi identificar os determi- M. B. Herrero participated in protocol design and data
nantes individuais e de rea da no-adeso ao trata- analysis, and was responsible in large part for preparing
mento da tuberculose (TB) em municpios de Buenos this manuscript. S. Arrossi was responsible for protocol
Aires, Argentina. Foi realizado um estudo transversal design, participated in data analysis, and in the writing
com um modelo hierarquizado. A anlise dos determi- of this manuscript. S. Ramos participated in protocol
nantes foi realizada em dois nveis por meio de an- design, data analysis, and in the writing of this manus-
lise de regresso logstica em dois nveis, com base em cript. J. U. Braga participated in data analysis and in the
dados primrios e secundrios. Alm disso, a falta de writing of this manuscript, and was responsible in large
abastecimento de gua em casa aumentou o risco de part for the final review of this manuscript.
no-adeso. Nesses domiclios, cujo chefe de famlia
no tinha a cobertura de sade, tambm o risco de
no-adeso foi maior, como em pacientes que usaram Acknowledgments
mais de um meio de transporte para chegar ao cen-
tro de sade. Em reas com uma maior proporo de The authors gratefully acknowledge: the support and
domiclios com uma rede de gs natural e com neces- resources provided by the Comisin Nacional Salud
sidades bsicas insatisfeitas para os meios de vida e Investiga of the Ministry of Health of Argentina; the su-
uma maior proporo de domiclios sem sanitrios foi pport of the Regional Director of the Tuberculosis Con-
maior o risco de no-adeso. Conclui-se que os fatores trol Program in the Sixth Health Region; and all the pa-
sociais e econmicos influenciam a adeso ao trata- tients who kindly participated in this study and shared
mento da TB, tanto individualmente como em termos their stories and made this study possible.
de rea.
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de Enfermedades Respiratorias Dr. Emilio Coni; Submitted on 16/Feb/2014
2008. Final version resubmitted on 24/Mar/2015
Approved on 30/Mar/2015