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Nguyen HB, Vo LNQ, Forse RJ, Wiemers AMC, Huynh HB, Dong TTT, Phan YTH, Creswell J, Dang TMH, Nguyen LH, Shedrawy J, Lönnroth K, Nguyen TD, Dinh LV, Annerstedt KS, Codlin AJ. Is convenience really king? Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam: a longitudinal patient cost study. Infect Dis Poverty 2024; 13:27. [PMID: 38528604 DOI: 10.1186/s40249-024-01196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector. METHODS Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression. RESULTS The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P < 0.001). This resulted in no significant difference in catastrophic costs between the two cohorts (Private: 55% vs NTP: 52%; P = 0.675). Factors associated with catastrophic cost included being a single-person household [adjusted odds ratio (aOR = 13.71; 95% confidence interval (CI): 1.36-138.14; P = 0.026], unemployment during treatment (aOR = 10.86; 95% CI: 2.64-44.60; P < 0.001) and experiencing TB-related stigma (aOR = 37.90; 95% CI: 1.72-831.73; P = 0.021). CONCLUSIONS Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.
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Affiliation(s)
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi, Viet Nam.
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Huy Ba Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | | | | | | | - Jad Shedrawy
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | | | - Kristi Sidney Annerstedt
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
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Noia Maciel EL, Negri LDSA, Guidoni LM, Fregona GC, Johansen FDC, Sanchez MN, Moreira ADSR, Diaz-Quijano FA, Tonini M, Zandonade E, Ershova J, Nguhiu P, Baena IG. The economic burden of households affected by tuberculosis in Brazil: First national survey results, 2019-2021. PLoS One 2023; 18:e0287961. [PMID: 38091306 PMCID: PMC10718450 DOI: 10.1371/journal.pone.0287961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 06/19/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND One of the three main targets of the World Health Organization (WHO) End TB Strategy (2015-2035) is that no tuberculosis (TB) patients or their households face catastrophic costs (defined as exceeding 20% of the annual household income) because of the disease. Our study seeks to determine, as a baseline, the magnitude and main drivers of the costs associated with TB disease for patients and their households and to monitor the proportion of households experiencing catastrophic costs in Brazil. METHODS A national cross-sectional cluster-based survey was conducted in Brazil in 2019-2021 following WHO methodology. TB patients of all ages and types of TB were eligible for the survey. Adult TB patients and guardians of minors (<18 years old) were interviewed once about costs, time loss, coping measures, income, household expenses, and asset ownership. Total costs, including indirect costs measured as reported household income change, were expressed as a percentage of annual household income. We used descriptive statistics to analyze the cost drivers and multivariate logistic regression to determine factors associated with catastrophic costs. RESULTS We interviewed 603 patients, including 538 (89%) with drug-sensitive (DS) and 65 (11%) with drug-resistant (DR) TB. Of 603 affected households, 48.1% (95%CI: 43-53.2) experienced costs above 20% of their annual household income during their TB episode. The proportion was 44.4% and 78.5% among patients with DS- and DR-TB, respectively. On average, patients incurred costs of US$1573 (95%CI: 1361.8-1785.0) per TB episode, including pre-diagnosis and post-diagnosis expenses. Key cost drivers were post-diagnosis nutritional supplements (US$317.6, 95%CI: 232.7-402.6) followed by medical costs (US$85.5, 95%CI: 54.3-116.5) and costs of travel for clinic visits during treatment (US$79.2, 95%CI: 61.9-96.5). In multivariate analysis, predictors of catastrophic costs included positive HIV status (aOR = 3.0, 95%CI:1.1-8.6) and self-employment (aOR = 2.7, 95%CI:1.1-6.5); high education was a protective factor (aOR = 0.1, 95%CI:0.0-0.9). CONCLUSIONS Although the services offered to patients with TB are free of charge in the Brazilian public health sector, the availability of free diagnosis and treatment services does not alleviate patients' financial burden related to accessing TB care. The study allowed us to identify the costs incurred by patients and suggest actions to mitigate their suffering. In addition, this study established a baseline for monitoring catastrophic costs and fostering a national policy to reduce the costs to patients for TB care in Brazil.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Maiko Tonini
- University of Brasília, UNB, Brasília, DF, Brazil
| | | | - Julia Ershova
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Peter Nguhiu
- KEMRI- Wellcome Trust Research Program, Health Economics Research Unit, Nairobi, Kenya
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Loureiro RB, Guidoni LM, Fregona GC, de Oliveira SMDVL, Sacramento D, Pinheiro JDS, Gomes D, Maciel ELN. Follow-up of patients diagnosed with and treated for tuberculosis in Brazil: financial burden on the household. J Bras Pneumol 2023; 49:e20220368. [PMID: 37610956 PMCID: PMC10578937 DOI: 10.36416/1806-3756/e20220368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/21/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE To evaluate the implications of the proportion of annual family income spent in the pre- and post-diagnosis periods in tuberculosis patients followed for after at least one year after completing tuberculosis treatment in Brazil. METHODS This was a cross-sectional study of tuberculosis patients followed for at least one year after completing tuberculosis treatment in five Brazilian capitals (one in each region of the country). RESULTS A total of 62 patients were included in the analysis. The overall average cost of tuberculosis was 283.84 Brazilian reals (R$) in the pre-diagnosis period and R$4,161.86 in the post-diagnosis period. After the costs of tuberculosis disease, 71% of the patients became unemployed, with an overall increase in unemployment; in addition, the number of patients living in nonpoverty decreased by 5%, the number of patients living in poverty increased by 6%, and the number of patients living in extreme poverty increased by 5%. The largest proportion of annual household income to cover the total costs of tuberculosis was for the extremely poor (i.e., 40.37% vs. 11.43% for the less poor). CONCLUSIONS Policies to mitigate catastrophic costs should include interventions planned by the health care system and social protection measures for tuberculosis patients with lower incomes in order to eliminate the global tuberculosis epidemic by 2035-a WHO goal in line with the United Nations Sustainable Development Goals.
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Affiliation(s)
- Rafaela Borge Loureiro
- . Programa de Pós-Graduação em Saúde Coletiva - PPGSC - Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
- . Laboratório de Epidemiologia, Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
| | - Leticia Molino Guidoni
- . Laboratório de Epidemiologia, Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
| | - Geisa Carlesso Fregona
- . Laboratório de Epidemiologia, Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
- . Programa de Tuberculose, Hospital Universitário Cassiano Antônio Moraes - HUCAM - Vitória (ES) Brasil
| | - Sandra Maria do Valle Leone de Oliveira
- . Programa de Pós-Graduação em Doenças Infecciosas e Parasitárias, Universidade Federal de Mato Grosso do Sul - UFMS - Campo Grande (MS) Brasil
- . Fiocruz Mato Grosso do Sul, Campo Grande (MS) Brasil
| | - Daniel Sacramento
- . Núcleo de Controle da Tuberculose, Secretaria Municipal de Saúde de Manaus, Manaus (AM) Brasil
| | - Jair dos Santos Pinheiro
- . Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas/Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus (AM) Brasil
- . Programa Estadual de Controle da Tuberculose do Amazonas/Fundação de Vigilância em Saúde - Dra. Rosemary Costa Pinto, Manaus (AM) Brasil
| | - Denise Gomes
- . Centro de Referência à Tuberculose - CRTB - GCC/SCS, Porto Alegre (RS) Brasil
| | - Ethel Leonor Noia Maciel
- . Programa de Pós-Graduação em Saúde Coletiva - PPGSC - Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
- . Laboratório de Epidemiologia, Universidade Federal do Espírito Santo - UFES - Vitória (ES) Brasil
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Malhotra A, Nonyane BAS, Shirey E, Mulder C, Hippner P, Mulatu F, Ratshinanga A, Mitiku P, Cohn S, Conradie G, Chihota V, Chaisson RE, Churchyard GJ, Golub J, Dowdy D, Sohn H, Charalambous S, Bedru A, Salazar-Austin N. Pragmatic cluster-randomized trial of home-based preventive treatment for TB in Ethiopia and South Africa (CHIP-TB). Trials 2023; 24:475. [PMID: 37491264 PMCID: PMC10367260 DOI: 10.1186/s13063-023-07514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/16/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Each year, 1 million children develop TB resulting in over 200,000 child deaths. TB preventive treatment (TPT) is highly effective in preventing TB but remains poorly implemented for household child contacts. Home-based child contact management and TPT services may improve access to care. In this study, we aim to evaluate the effectiveness and cost-effectiveness of home-based contact management with TPT initiation in two TB high-burden African countries, Ethiopia and South Africa. METHODS This pragmatic cluster randomized trial compares home-based versus facility-based care delivery models for contact management. Thirty-six clinics with decentralized TB services (18 in Ethiopia and 18 in South Africa) were randomized in a 1:1 ratio to conduct either home-based or facility-based contact management. The study will attempt to enroll all eligible close child contacts of infectious drug-sensitive TB index patients diagnosed and treated for TB by one of the study clinics. Child TB contact management, including contact tracing, child evaluation, and TPT initiation and follow-up, will take place in the child's home for the intervention arm and at the clinic for the control arm. The primary outcome is the cluster-level ratio of the number of household child contacts less than 15 years of age in Ethiopia and less than 5 years of age in South Africa initiated on TPT per index patient, comparing the intervention to the control arm. Secondary outcomes include child contact identification and the TB prevention continuum of care. Other implementation outcomes include acceptability, feasibility, fidelity, cost, and cost-effectiveness of the intervention. DISCUSSION This implementation research trial will determine whether home-based contact management identifies and initiates more household child contacts on TPT than facility-based contact management. TRIAL REGISTRATION NCT04369326 . Registered on April 30, 2020.
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Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Evan Shirey
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christiaan Mulder
- Department of TB Elimination and Health System Innovations, KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Piotr Hippner
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | | | | | | | - Silvia Cohn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Violet Chihota
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Richard E Chaisson
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin J Churchyard
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Jonathan Golub
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Salome Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Nicole Salazar-Austin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Brown LK, Van Schalkwyk C, De Villiers AK, Marx FM. Impact of interventions for tuberculosis prevention and care in South Africa - a systematic review of mathematical modelling studies. S Afr Med J 2023; 113:125-134. [PMID: 36876352 DOI: 10.7196/samj.2023.v113i3.16812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Substantial additional efforts are needed to prevent, find and successfully treat tuberculosis (TB) in South Africa (SA). In thepast decade, an increasing body of mathematical modelling research has investigated the population-level impact of TB prevention and careinterventions. To date, this evidence has not been assessed in the SA context. OBJECTIVE To systematically review mathematical modelling studies that estimated the impact of interventions towards the World HealthOrganization's End TB Strategy targets for TB incidence, TB deaths and catastrophic costs due to TB in SA. METHODS We searched the PubMed, Web of Science and Scopus databases for studies that used transmission-dynamic models of TB in SAand reported on at least one of the End TB Strategy targets at population level. We described study populations, type of interventions andtheir target groups, and estimates of impact and other key findings. For studies of country-level interventions, we estimated average annualpercentage declines (AAPDs) in TB incidence and mortality attributable to the intervention. RESULTS We identified 29 studies that met our inclusion criteria, of which 7 modelled TB preventive interventions (vaccination,antiretroviral treatment (ART) for HIV, TB preventive treatment (TPT)), 12 considered interventions along the care cascade for TB(screening/case finding, reducing initial loss to follow-up, diagnostic and treatment interventions), and 10 modelled combinationsof preventive and care-cascade interventions. Only one study focused on reducing catastrophic costs due to TB. The highest impactof a single intervention was estimated in studies of TB vaccination, TPT among people living with HIV, and scale-up of ART. Forpreventive interventions, AAPDs for TB incidence varied between 0.06% and 7.07%, and for care-cascade interventions between 0.05%and 3.27%. CONCLUSION We describe a body of mathematical modelling research with a focus on TB prevention and care in SA. We found higherestimates of impact reported in studies of preventive interventions, highlighting the need to invest in TB prevention in SA. However, studyheterogeneity and inconsistent baseline scenarios limit the ability to compare impact estimates between studies. Combinations, rather thansingle interventions, are likely needed to reach the End TB Strategy targets in SA.
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Affiliation(s)
- L K Brown
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa.
| | - C Van Schalkwyk
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa.
| | - A K De Villiers
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - F M Marx
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany.
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Ghazy RM, Sallam M, Ashmawy R, Elzorkany AM, Reyad OA, Hamdy NA, Khedr H, Mosallam RA. Catastrophic Costs among Tuberculosis-Affected Households in Egypt: Magnitude, Cost Drivers, and Coping Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20032640. [PMID: 36768005 PMCID: PMC9915462 DOI: 10.3390/ijerph20032640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 05/31/2023]
Abstract
Despite national programs covering the cost of treatment for tuberculosis (TB) in many countries, TB patients still face substantial costs. The end TB strategy, set by the World Health Organization (WHO), calls for "zero" TB households to be affected by catastrophic payments by 2025. This study aimed to measure the catastrophic healthcare payments among TB patients in Egypt, to determine its cost drivers and determinants and to describe the coping strategies. The study utilized an Arabic-validated version of the TB cost tool developed by the WHO for estimating catastrophic healthcare expenditure using the cluster-based sample survey with stratification in seven administrative regions in Alexandria. TB payments were considered catastrophic if the total cost exceeded 20% of the household's annual income. A total of 276 patients were interviewed: 76.4% were males, 50.0% were in the age group 18-35, and 8.3% had multidrug-resistant TB. Using the human capital approach, 17.0% of households encountered catastrophic costs compared to 59.1% when using the output approach. The cost calculation was carried out using the Egyptian pound converted to the United States dollars based on 2021 currency values. Total TB cost was United States dollars (USD) 280.28 ± 29.9 with a total direct cost of USD 103 ± 10.9 and a total indirect cost of USD 194.15 ± 25.5. The direct medical cost was the main cost driver in the pre-diagnosis period (USD 150.23 ± 26.89 pre diagnosis compared to USD 77.25 ± 9.91 post diagnosis, p = 0.013). The indirect costs (costs due to lost productivity) were the main cost driver in the post-diagnosis period (USD 4.68 ± 1.18 pre diagnosis compared to USD 192.84 ± 25.32 post diagnosis, p < 0.001). The households drew on multiple financial strategies to cope with TB costs where 66.7% borrowed and 25.4% sold household property. About two-thirds lost their jobs and another two-thirds lowered their food intake. Being female, delay in diagnosis and being in the intensive phase were significant predictors of catastrophic payment. Catastrophic costs were high among TB households in Alexandria and showed wide variation according to the method used for indirect cost estimation. The main cost driver before diagnosis was the direct medical costs, while it was the indirect costs, post diagnosis.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria 21561, Egypt
| | - Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| | - Rasha Ashmawy
- Department of Clinical Research, Maamora Chest Hospital, Alexandria 21923, Egypt
| | | | - Omar Ahmed Reyad
- Internal Medicine and Cardiology Clinical Pharmacy Department, Alexandria University Main Hospital, Alexandria 21526, Egypt
| | - Noha Alaa Hamdy
- Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
| | - Heba Khedr
- MDR-TB Center, Maamora Chest Hospital, Alexandria 21912, Egypt
| | - Rasha Ali Mosallam
- Department of Health Administration and Behavioral Science, High Institute of Public Health, Alexandria University, Alexandria 21561, Egypt
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de Guex KP, Augustino D, Mejan P, Gadiye R, Massong C, Lukumay S, Msoka P, Sariko M, Kimathi D, Vinnard C, Xie Y, Mmbaga B, Pfaeffle H, Geba M, Heysell SK, Mduma E, Thomas TA. Roadblocks and resilience: A qualitative study of the impact of pediatric tuberculosis on Tanzanian households and solutions from caregivers. Glob Public Health 2023; 18:2196569. [PMID: 37021699 PMCID: PMC10228591 DOI: 10.1080/17441692.2023.2196569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023]
Abstract
Distinct from quantifying the economic sequelae of tuberculosis (TB) in adults, data are scarce regarding lived experiences of youth and their caregivers seeking and sustaining TB treatment in low income communities. Children ages 4-17 diagnosed with TB and their caregivers were recruited from rural and semi-urban northern Tanzania. Using a grounded theory approach, a qualitative interview guide was developed, informed by exploratory research. Twenty-four interviews were conducted in Kiswahili, audio-recorded and analyzed for emerging and consistent themes. Dominant themes found were socioemotional impacts of TB on households, including adverse effects on work productivity, and facilitators and obstacles to TB care, including general financial hardship and transportation challenges. The median percentage of household monthly income spent to attend a TB clinic visit was 34% (minimum: 1%, maximum: 220%). The most common solutions identified by caregivers to mitigate adverse impacts were transportation assistance and nutrition supplementation. To end TB, healthcare systems must acknowledge the total financial burden shouldered by low wealth families seeking pediatric TB care, provide consultations and medications locally, and increase access to TB-specific communal funds to mitigate burdens such as inadequate nutrition.Trial registration: planned sub-study of the registered prospective study, NCT05283967.Trial registration: ClinicalTrials.gov identifier: NCT05283967.
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Affiliation(s)
- Kristen Petros de Guex
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, USA
| | | | - Paulo Mejan
- Haydom Global Health Research Center, Haydom, Tanzania
| | - Rehema Gadiye
- Haydom Global Health Research Center, Haydom, Tanzania
| | | | | | - Perry Msoka
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | | | | | | | - Yingda Xie
- Rutgers New Jersey Medical School, Division of Infectious Diseases, Newark, USA
| | | | | | - Maria Geba
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, USA
| | - Scott K. Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, USA
| | - Estomih Mduma
- Haydom Global Health Research Center, Haydom, Tanzania
| | - Tania A. Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, USA
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Addo J, Pearce D, Metcalf M, Lundquist C, Thomas G, Barros-Aguirre D, Koh GCKW, Strange M. Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment. BMC Public Health 2022; 22:1717. [PMID: 36085073 PMCID: PMC9462890 DOI: 10.1186/s12889-022-14115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/30/2022] [Indexed: 02/06/2023] Open
Abstract
Abstract
Background
Although tuberculosis (TB) is a curable disease, treatment is complex and prolonged, requiring considerable commitment from patients. This study aimed to understand the common perspectives of TB patients across Brazil, Russia, India, China, and South Africa throughout their disease journey, including the emotional, psychological, and practical challenges that patients and their families face.
Methods
This qualitative market research study was conducted between July 2020 and February 2021. Eight TB patients from each country (n = 40) completed health questionnaires, video/telephone interviews, and diaries regarding their experiences of TB. Additionally, 52 household members were interviewed. Patients at different stages of their TB treatment journey, from a range of socioeconomic groups, with or without TB risk factors were sought. Anonymized data underwent triangulation and thematic analysis by iterative coding of statements.
Results
The sample included 23 men and 17 women aged 13–60 years old, with risk factors for TB reported by 23/40 patients. Although patients were from different countries and cultural backgrounds, experiencing diverse health system contexts, five themes emerged as common across the sample. 1) Economic hardship from loss of income and medical/travel expenses. 2) Widespread stigma, delaying presentation and deeply affecting patients’ emotional wellbeing. 3) TB and HIV co-infection was particularly challenging, but increased TB awareness and accelerated diagnosis. 4) Disruption to family life strained relationships and increased patients’ feelings of isolation and loneliness. 5) The COVID-19 pandemic made it easier for TB patients to keep their condition private, but disrupted access to services.
Conclusions
Despite disparate cultural, socio-economic, and systemic contexts across countries, TB patients experience common challenges. A robust examination of the needs of individual patients and their families is required to improve the patient experience, encourage adherence, and promote cure, given the limitations of current treatment.
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Zawedde-Muyanja S, Manabe YC, Cattamanchi A, Castelnuovo B, Katamba A. Patient and health system level barriers to and facilitators for tuberculosis treatment initiation in Uganda: a qualitative study. BMC Health Serv Res 2022; 22:831. [PMID: 35764982 PMCID: PMC9513807 DOI: 10.1186/s12913-022-08213-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The WHO END TB strategy targets to place at least 90% of all patients diagnosed with Tuberculosis (TB) on appropriate treatment. In Uganda, approximately 20% of patients diagnosed with TB are not initiated on TB treatment. We sought to identify the patient and health system level barriers to and facilitators for TB treatment initiation in Uganda. METHODS We conducted the study at ten public health facilities (three primary care, four district and three tertiary referral hospitals). We carried out in-depth interviews with patients diagnosed with TB and key informant interviews with health managers. In addition, we held focus group discussions with healthcare workers involved in TB care. Data collection and thematic analysis of transcripts was informed by the Capability, Opportunity, Motivation and Behavior (COM-B) model. We identified relevant intervention functions using the Behavior Change Wheel. RESULTS We interviewed 79 respondents (31 patients, 10 health managers and 38 healthcare workers). Common barriers at the health facility level included; lack of knowledge about the proportion of patients not initiated on TB treatment (psychological capability); difficulty accessing sputum results from the laboratory as well as difficulty tracing patients due to inadequate recording of patient addresses (physical opportunity). At the patient level, notable barriers included long turnaround time for sputum results and lack of transport funds to return to health facilities (physical opportunity); limited TB knowledge (psychological capability) and stigma (social opportunity). The most important facilitators identified were quick access to sputum test results either on the date of first visit (same-day diagnosis) or on the date of first return and availability of TB treatment (physical opportunity). We identified education, restructuring of the service environment to improve sputum results turnaround time and enablement to improve communication of test results as relevant intervention functions to alleviate these barriers to and enhance facilitators for TB treatment initiation. CONCLUSION We found that barriers to treatment initiation existed at both the patient and health facility-level across all levels of the (Capability, Opportunity and Motivation) model. The intervention functions identified here should be tested for feasibility.
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Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda.
| | - Yukari C Manabe
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco California, USA.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Barbara Castelnuovo
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda. .,Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital Complex, P.O. Box 7072, Kampala, Uganda.
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10
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Mmolawa L, Siwelana T, Hanrahan CF, Lebina L, Martinson NA, Dowdy D, Nonyane BAS. Time to care-seeking for TB symptoms. Int J Tuberc Lung Dis 2022; 26:268-275. [PMID: 35197167 PMCID: PMC9636494 DOI: 10.5588/ijtld.21.0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Early presentation to healthcare facilities is critical for early diagnosis and treatment of TB. We studied self-reported time to care-seeking from the onset of TB symptoms among primary healthcare clinic (PHC) attendees in Limpopo Province, South Africa.METHODS: We used data from participants enrolled in a cluster-randomized trial of TB case finding in 56 PHC clinics across two health districts. We fitted log-normal accelerated failure time regression models and we present time ratios (TRs) for potential risk factors.RESULTS: We included 2,160 participants. Among the 1,757 (81%) diagnosed with active TB, the median time to care-seeking was 30 days (IQR 14-60); adults sought care later than children/adolescents (adjusted TR aTR 1.47, 95% CI 1.10-1.96). Among those not diagnosed with TB, the median was 14 days (IQR 7-60); being HIV-positive (aTR 1.57, 95% CI 1.03-2.40); having less than grade 8 education and currently smoking were associated with longer time to care-seeking. In the combined analysis, living with HIV and having underlying active TB was associated with faster care-seeking (TB status x HIV interaction: TR 0.68, 95% CI 0.48-0.96).CONCLUSION: Delay in care-seeking was associated with age, lower education and being a current smoker. TB awareness campaigns targeting these population groups may improve care-seeking behavior and reduce community TB transmission.
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Affiliation(s)
- L Mmolawa
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - T Siwelana
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - C F Hanrahan
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - L Lebina
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - D Dowdy
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - B A S Nonyane
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
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11
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Malik B, Hasan Farooqui H, Bhattacharyya S. Disparity in socio-economic status explains the pattern of self-medication of antibiotics in India: understanding from game-theoretic perspective. ROYAL SOCIETY OPEN SCIENCE 2022; 9:211872. [PMID: 35154800 PMCID: PMC8826305 DOI: 10.1098/rsos.211872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/11/2022] [Indexed: 05/14/2023]
Abstract
The emergence of antimicrobial resistance has raised great concern for public health in many lower-income countries including India. Socio-economic determinants like poverty, health expenditure and awareness accelerate this emergence by influencing individuals' attitudes and healthcare practices such as self-medication. This self-medication practice is highly prevalent in many countries, where antibiotics are available without prescriptions. Thus, complex dynamics of drug- resistance driven by economy, human behaviour, and disease epidemiology poses a serious threat to the community, which has been less emphasized in prior studies. Here, we formulate a game-theoretic model of human choices in self-medication integrating economic growth and disease transmission processes. We show that this adaptive behaviour emerges spontaneously in the population through a self-reinforcing process and continual feedback from the economy, resulting in the emergence of resistance as externalities of human choice under resource constraints situations. We identify that the disparity between social-optimum and individual interest in self-medication is primarily driven by the effectiveness of treatment, health awareness and public health interventions. Frequent multiple-peaks of resistant strains are also observed when individuals imitate others more readily and self-medication is more likely. Our model exemplifies that timely public health intervention for financial risk protection, and antibiotic stewardship policies can improve the epidemiological situation and prevent economic collapse.
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Affiliation(s)
- Bhawna Malik
- Disease Modelling Lab, Mathematics, School of Natural Sciences, Shiv Nadar University, Greater Noida, India
| | - Habib Hasan Farooqui
- Indian Institute of Public Health, Public Health Foundation of India, Delhi, India
- College of Medicine, Qatar University, Doha, Qatar
| | - Samit Bhattacharyya
- Disease Modelling Lab, Mathematics, School of Natural Sciences, Shiv Nadar University, Greater Noida, India
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12
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Ghazy RM, El Saeh HM, Abdulaziz S, Hammouda EA, Elzorkany AM, Khidr H, Zarif N, Elrewany E, Abd ElHafeez S. A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep 2022; 12:558. [PMID: 35017604 PMCID: PMC8752613 DOI: 10.1038/s41598-021-04345-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
One of the strategies of the World Health Organization End Tuberculosis (TB) was to reduce the catastrophic costs incurred by TB-affected families to 0% by 2020.Catastrophic cost is defined by the total cost related to TB management exceeding 20% of the annual pre-TB household income. This study aimed to estimate the pooled proportion of TB affected households who incurred catastrophic costs. We searched PubMed, SciELO, Scopus, Embase, Google Scholar, ProQuest, SAGE, and Web of Science databases according to Preferred Reporting Items of the Systematic Reviews and Meta-Analysis (PRISMA) guidelines till November 20, 2020. Eligible studies were identified and data on catastrophic costs due to TB were extracted. We performed a meta-analysis to generate the pooled proportion of patients with TB facing catastrophic costs. From 5114 studies identified, 29 articles were included in the final analysis. The pooled proportion of patients faced catastrophic costs was (43%, 95% CI [34-51]). Meta-regression revealed that country, drug sensitivity, and Human immune-deficiency Virus (HIV) co-infection were the main predictors of such costs. Catastrophic costs incurred by drug sensitive, drug resistant, and HIV co-infection were 32%, 81%, and 81%, respectively. The catastrophic costs incurred were lower among active than passive case findings (12% vs. 30%). Half (50%) of TB-affected households faced catastrophic health expenditure at 10% cut-off point. The financial burden of patients seeking TB diagnosis and treatment continues to be a worldwide impediment. Therefore, the End TB approach should rely on socioeconomic support and cost-cutting initiatives.PROSPERO registration: CRD42020221283.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Haider M El Saeh
- Community Medicine Department, Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | - Heba Khidr
- Ministry of Health and Population, Alexandria, Egypt
| | - Nardine Zarif
- Ministry of Health and Population, Alexandria, Egypt
| | - Ehab Elrewany
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Samar Abd ElHafeez
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
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13
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Viney K, Itogo N, Yamanaka T, Jebeniani R, Hazarika A, Morishita F, Nishikiori N, Nery SV. Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands. BMC Public Health 2021; 21:1928. [PMID: 34688266 PMCID: PMC8542301 DOI: 10.1186/s12889-021-11938-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) care can be costly for patients and their families. The End TB Strategy includes a target that zero TB affected households should experience catastrophic costs associated with TB care. Costs are catastrophic when a patient spends 20% or more of their annual household income on their TB diagnosis and care. In Solomon Islands the costs of TB care are unknown. The aim of this study was to determine the costs of TB diagnosis and care, the types of costs and the proportion of patients with catastrophic costs. METHODS This was a nationally representative cross-sectional survey of TB patients carried out between 2017 and 2019. Patients were recruited from health care facilities, from all ten provinces in Solomon Islands. During an interview they were asked about the costs of TB diagnosis and care. These data were analysed using descriptive statistics to describe the costs overall and the proportions of different types of costs. The proportion of patients with catastrophic costs was calculated and a multivariate logistic regression was undertaken to determine factors associated with catastrophic costs. RESULTS One hundred and eighty-three TB patients participated in the survey. They spent a mean of 716 USD (inter quartile range: 348-1217 USD) on their TB diagnosis and care. Overall, 62.1% of costs were attributable to non-medical costs, while income loss and medical costs comprised 28.5 and 9.4%, respectively. Overall, 19.7% (n = 36) of patients used savings, borrowed money, or sold assets as a financial coping mechanism. Three patients (1.6%) had health insurance. A total of 92.3% (95% CI: 88.5-96.2) experienced catastrophic costs, using the output approach. Being in the first, second or third poorest wealth quintile was significantly associated with catastrophic costs (adjusted odds ratio: 67.3, 95% CI: 15.86-489.74%, p < 0.001). CONCLUSION The costs of TB care are catastrophic for almost all patients in Solomon Islands. The provision of TB specific social and financial protection measures from the National TB and Leprosy Programme may be needed in the short term to ameliorate these costs. In the longer term, advancement of universal health coverage and other social and financial protection measures should be pursued.
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Affiliation(s)
- Kerri Viney
- Research School of Population Health, Australian National University, Canberra, Australia.
- Global TB Programme, World Health Organization Headquarters, Geneva, Switzerland.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Noel Itogo
- National TB Programme, Ministry of Health and Medical Services, Honiara, Solomon Islands
- World Health Organization Country Office, Honiara, Solomon Islands
| | - Takuya Yamanaka
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- School of Tropical Medicine & Global Health, Nagasaki University, Nagasaki, Japan
| | | | - Anupama Hazarika
- World Health Organization Country Office, Honiara, Solomon Islands
| | - Fukushi Morishita
- End TB and Leprosy Unit, World Health Organization Regional Office of the Western Pacific, Manila, Philippines
| | - Nobuyuki Nishikiori
- Global TB Programme, World Health Organization Headquarters, Geneva, Switzerland
| | - Susana Vaz Nery
- Research School of Population Health, Australian National University, Canberra, Australia
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
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Ellaban MM, Basyoni NI, Boulos DNK, Rady M, Gadallah M. Assessment of Household Catastrophic Total Cost of Tuberculosis and Its Determinants in Cairo: Prospective Cohort Study. Tuberc Respir Dis (Seoul) 2021; 85:165-174. [PMID: 34814238 PMCID: PMC8987667 DOI: 10.4046/trd.2021.0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 09/01/2021] [Indexed: 11/24/2022] Open
Abstract
Background One goal of the End tuberculosis (TB) Strategy is to see no TB-affected households experiencing catastrophic costs. Therefore, it is crucial for TB-elimination programs to identify catastrophic costs and their main drivers in order to establish appropriate health and social measures. This study aimed to measure the percent of catastrophic costs experienced by Egyptian TB patients and to identify its determinants. Methods We conducted a prospective cohort study with 151 Egyptian TB patients recruited from two chest dispensaries from the Cairo governate from May 2019 to May 2020. We used a validated World Health Organization TB patient-cost tool to collect data on patients’ demographic information, household income, and direct and indirect expense of seeking TB treatment. We considered catastrophic TB costs to be total costs exceeding 20% of the household’s annual income. Results Of the patients, 33% experienced catastrophic costs. The highest proportion of the total came in the pretreatment stage. Being the main breadwinner, experiencing job loss, selling property, and the occurrence of early coronavirus disease 2019 lockdown were independent determinants of the incidence of catastrophic costs. Borrowing money and selling property were the most-often reported coping strategies adopted. Conclusion Despite the availability of free TB care under the Egyptian National TB Program, nearly a third of the TB patients incurred catastrophic costs. Job loss and being the main breadwinner were among the significant predictors of catastrophic costs. Social protection mechanisms, including cash assistance and insurance coverage, are necessary to achieve the goal of the End TB Strategy.
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Affiliation(s)
- Manar M Ellaban
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nashwa I Basyoni
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dina N K Boulos
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mervat Rady
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohsen Gadallah
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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15
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Tadokera R, Huo S, Theron G, Timire C, Manyau-Makumbirofa S, Metcalfe JZ. Health care seeking patterns of rifampicin-resistant tuberculosis patients in Harare, Zimbabwe: A prospective cohort study. PLoS One 2021; 16:e0254204. [PMID: 34270593 PMCID: PMC8284678 DOI: 10.1371/journal.pone.0254204] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Delays in seeking and accessing treatment for rifampicin-resistant tuberculosis (RR-TB) and multi-drug resistant (MDR-TB) are major impediments to TB control in high-burden, resource-limited settings. Method We prospectively determined health-seeking behavioural patterns and associations with treatment outcomes and costs among 68 RR-TB patients attending conveniently selected facilities in a decentralised system in Harare, Zimbabwe. Results From initial symptoms to initiation of effective treatment, patients made a median number of three health care visits (IQR 2–4 visits) at a median cost of 13% (IQR 6–31%) of their total annual household income (mean cost, US$410). Cumulatively, RR-TB patients most frequently first visited private facilities, i.e., private pharmacies (30%) and other private health care providers (24%) combined. Median patient delay was 26 days (IQR 14–42 days); median health system delay was 97 days (IQR 30–215 days) and median total delay from symptom onset to initiation of effective treatment was 132 days (IQR 51–287 days). The majority of patients (88%) attributed initial delay in seeking care to “not feeling sick enough.” Total delay, total cost and number of health care visits were not associated with treatment or clinical outcomes, though our study was not adequately powered for these determinations. Conclusions Despite the public availability of rapid molecular TB tests, patients experienced significant delays and high costs in accessing RR-TB treatment. Active case finding, integration of private health care providers and enhanced service delivery may reduce treatment delay and TB associated costs.
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Affiliation(s)
- Rebecca Tadokera
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, NRF/DST Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Stella Huo
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
| | - Grant Theron
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, NRF/DST Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Collins Timire
- Ministry of Health and Child Care, National Tuberculosis Control Programme, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease Zimbabwe Office, Centre for Operational Research, Harare, Zimbabwe
| | - Salome Manyau-Makumbirofa
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
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Kamchedzera W, Maheswaran H, Squire SB, Joekes E, Pai M, Nliwasa M, G Lalloo D, Webb EL, Corbett EL, MacPherson P. Economic costs of accessing tuberculosis (TB) diagnostic services in Malawi: an analysis of patient costs from a randomised controlled trial of computer-aided chest x-ray interpretation. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16683.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Patients with tuberculosis (TB) symptoms in low-resource settings face convoluted diagnostic and treatment linkage pathways, incurring substantial health-seeking costs. In the context of a randomised trial looking at the impact of novel diagnostics such as computer-aided chest x-ray diagnosis (CAD4TB), we aimed to investigate the costs incurred by patients seeking TB diagnosis and whether optimised diagnostic interventions could result in a reduction in the cost faced by households. Methods: PROSPECT was a three-arm randomised trial conducted in a public primary health clinic in Blantyre, Malawi during 2018-2019 (trial arms: standard of care [SOC]; HIV testing [HIV]; HIV testing and CAD4TB [HIV/TB]). The direct and indirect costs incurred by 219 PROSPECT participants over the 56-day follow-up period were collected. Costs were deemed catastrophic if they exceeded 20% of annual household income. We compared mean costs and used generalised linear regression models to examine whether the interventions could result in a reduction in total costs. Results: The mean total cost incurred by all 219 participants was US$12.11 (standard error (SE): 1.86). The indirect and direct cost was US$8.47 (SE: 1.66) and US$3.64 (SE: 0.38), respectively. The mean total cost composed of 5.6% of the average annual household income. In total, 5% (9/180) of the participants with complete income data incurred catastrophic costs. Compared to SOC, there was no statistically significant difference in the mean total cost faced by those in the HIV (ratio: 0.77, 95% CI: 0.51, 1.19) and HIV/TB arms (ratio: 0.85, 95% CI: 0.53, 1.37). Conclusions: Despite the absence of user fees, patients seeking healthcare with TB symptoms incurred catastrophic costs. The optimised TB diagnostic interventions that were investigated in the PROSPECT study did not significantly reduce costs. TB diagnosis interventions should be implemented alongside social protection policies whilst ensuring healthcare facilities are accessible by the poor.
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Gurung SC, Rai B, Dixit K, Worrall E, Paudel PR, Dhital R, Sah MK, Pandit RN, Aryal TP, Majhi G, Wingfield T, Squire B, Lönnroth K, Levy JW, Viney K, van Rest J, Ramsay A, Santos da Costa RM, Basnyat B, Thapa A, Mishra G, Moreira Pescarini J, Caws M, Teixeira de Siqueira-Filha N. How to reduce household costs for people with tuberculosis: a longitudinal costing survey in Nepal. Health Policy Plan 2021; 36:594-605. [PMID: 33341891 PMCID: PMC8173598 DOI: 10.1093/heapol/czaa156] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to compare costs and socio-economic impact of tuberculosis (TB) for patients diagnosed through active (ACF) and passive case finding (PCF) in Nepal. A longitudinal costing survey was conducted in four districts of Nepal from April 2018 to October 2019. Costs were collected using the WHO TB Patient Costs Survey at three time points: intensive phase of treatment, continuation phase of treatment and at treatment completion. Direct and indirect costs and socio-economic impact (poverty headcount, employment status and coping strategies) were evaluated throughout the treatment. Prevalence of catastrophic costs was estimated using the WHO threshold. Logistic regression and generalized estimating equation were used to evaluate risk of incurring high costs, catastrophic costs and socio-economic impact of TB over time. A total of 111 ACF and 110 PCF patients were included. ACF patients were more likely to have no education (75% vs 57%, P = 0.006) and informal employment (42% vs 24%, P = 0.005) Compared with the PCF group, ACF patients incurred lower costs during the pretreatment period (mean total cost: US$55 vs US$87, P < 0.001) and during the pretreatment plus treatment periods (mean total direct costs: US$72 vs US$101, P < 0.001). Socio-economic impact was severe for both groups throughout the whole treatment, with 32% of households incurring catastrophic costs. Catastrophic costs were associated with 'no education' status [odds ratio = 2.53(95% confidence interval = 1.16-5.50)]. There is a severe and sustained socio-economic impact of TB on affected households in Nepal. The community-based ACF approach mitigated costs and reached the most vulnerable patients. Alongside ACF, social protection policies must be extended to achieve the zero catastrophic costs milestone of the End TB strategy.
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Affiliation(s)
- Suman Chandra Gurung
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Bhola Rai
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Kritika Dixit
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Eve Worrall
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Puskar Raj Paudel
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Raghu Dhital
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Manoj Kumar Sah
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | | | | | - Govinda Majhi
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
| | - Tom Wingfield
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Bertie Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Knut Lönnroth
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
| | - Jens W Levy
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Kerri Viney
- Karolinska Institutet, Department of Global Public Health, 171 77, Stockholm, Sweden
- Australian National University, Research School of Population Health, College of Health & Medicine, Canberra, ACT 2600, Australia
| | - Job van Rest
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB, Den Haag, the The Netherlands
| | - Andrew Ramsay
- University of St Andrews, College Gate St Andrews, KY16 9AJ, UK
| | - Rafaely Marcia Santos da Costa
- Oswaldo Cruz Foundation, Centro de Pesquisa Aggeu Magalhaes, Av. Professor Moraes Rego, s/n – Cidade Universitária – Recife/PE, CEP 50.740-465, Brazil
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, P. O. Box 26500, Kathmandu, Nepal
| | - Anil Thapa
- National Tuberculosis Control Centre, Thimi, Bhaktapur, Nepal
| | - Gokul Mishra
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Julia Moreira Pescarini
- Oswaldo Cruz Foundation, Centro de Integracao de Dados e Conhecimentos para Saude, Rua Mundo, 121, Trobogy, Salvador - Bahia, CEP 41745-715, Brazil
| | - Maxine Caws
- Birat Nepal Medical Trust: Lazimpat, Ward No. 2, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Noemia Teixeira de Siqueira-Filha
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
- University of York, Department of Helarh Sciences, Heslington, YO10 5DD, York, UK
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Evans D, van Rensburg C, Govathson C, Ivanova O, Rieß F, Siroka A, Sillah AK, Ntinginya NE, Jani I, Sathar F, Rosen S, Sanne I, Rachow A, Lönnroth K. Adaptation of WHO's generic tuberculosis patient cost instrument for a longitudinal study in Africa. Glob Health Action 2021; 14:1865625. [PMID: 33491593 PMCID: PMC7850383 DOI: 10.1080/16549716.2020.1865625] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
The WHO developed a generic 'TB patient cost survey' tool and a standardized approach to assess the direct and indirect costs of TB incurred by patients and their households, estimate the proportion of patients experiencing catastrophic costs, and measure the impact of interventions to reduce patient costs. While the generic tool is a facility-based cross-sectional survey, this standardized approach needs to be adapted for longitudinal studies. A longitudinal approach may overcome some of the limitations of a cross-sectional design and estimate the economic burden of TB more precisely. We describe the process of creating a longitudinal instrument and its application to the TB Sequel study, an ongoing multi-country, multi-center observational cohort study. We adapted the cross-sectional WHO generic TB patient cost survey instrument for the longitudinal study design of TB Sequel and the local context in each study country (South Africa, Mozambique, Tanzania, and The Gambia). The generic instrument was adapted for use at enrollment (start of TB treatment; Day 0) and at 2, 6, 12 and 24 months after enrollment, time points intended to capture costs incurred for diagnosis, during treatment, at the end of treatment, and during long-term follow-up once treatment has been completed. These time points make the adapted version suitable for use in patients with either drug-sensitive or drug-resistant TB. Using the adapted tool provides the opportunity to repeat measures and make comparisons over time, describe changes that extend beyond treatment completion, and link cost survey data to treatment outcomes and post-TB sequelae. Trial registration: ClinicalTrials.gov: NCT032516 August 1196, 2017. Abbreviations: DOTS: Directly observed treatment, short-course; DR-TB: Drug-resistant tuberculosis; MDR-TB: Multi-drug resistant tuberculosis; NTP: National Tuberculosis Programme; TB: Tuberculosis; USD: United States Dollar; WHO: World Health Organization.
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Affiliation(s)
- Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Olena Ivanova
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Friedrich Rieß
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Andrew Siroka
- Health Financing Department, World Health Organization , Geneva, Switzerland
| | - Abdou K Sillah
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine , Fajara, The Gambia
| | | | - Ilesh Jani
- Instituto Nacional de Sauúde (INS) , Maputo, Mozambique
| | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health , Boston, MA, USA
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Andrea Rachow
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institute , Stockholm, Sweden
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19
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Ghazy RM, Saeh HME, Abdulaziz S, Hammouda EA, Elzorkany A, Kheder H, Zarif N, Elrewany E, Elhafeez SA. A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households.. [DOI: 10.1101/2021.02.27.21252453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
AbstractBackgroundAs one of the World Health Organization (WHO) End Tuberculosis (TB) Strategy is to reduce the proportion of TB affected families that face catastrophic costs to 0% by 2020. This systematic review and meta-analysis aimed to estimate the pooled proportion of TB affected households who face catastrophic cost.MethodA search of the online database through September 2020 was performed. A total of 5114 articles were found, of which 29 articles got included in quantitative synthesis. Catastrophic cost is defined if total cost related to TB exceeded 20% of annual pre-TB household income. R software was used to estimate the pooled proportion at 95% confidence intervals (CIs) using the fixed/random-effect models.ResultThe proportion of patients faced catastrophic cost was 43% (95% CI 34-52, I2= 99%); 32% (95% CI 29 – 35, I2= 70%) among drug sensitive, and 80% (95% CI 74-85, I2= 54%) among drug resistant, and 81% (95%CI 78-84%, I2= 0%) among HIV patients. Regarding active versus passive case finding the pooled proportion of catastrophic cost was 12% (95% CI 9-16, I2= 95%) versus 42% (95% CI 35-50, I2= 94%). The pooled proportion of direct cost to the total cost was 45% (95% CI 39-51, I2= 91%). The pooled proportion of patients facing catastrophic health expenditure (CHE) at cut of point of 10% of their yearly income was 45% (95% CI 35-56, I2= 93%) while at 40% of their capacity to pay was 63% (95% CI 40-80, I2= 96%).ConclusionDespite the ongoing efforts, there is a significant proportion of patients facing catastrophic cost, which represent a main obstacle against TB control.PROSPERO registrationCRD42020221283
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20
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Fuady A, Houweling TAJ, Richardus JH. COVID-19 and Tuberculosis-Related Catastrophic Costs. Am J Trop Med Hyg 2020; 104:436-440. [PMID: 33269683 PMCID: PMC7866313 DOI: 10.4269/ajtmh.20-1125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/23/2020] [Indexed: 12/13/2022] Open
Abstract
The COVID-19 pandemic has created an unprecedented health crisis and a substantial socioeconomic impact. It also affects tuberculosis (TB) control severely worldwide. Interruptions of many TB control programs because of the COVID-19 pandemic could result in significant setbacks. One of the targets that can be affected is the WHO's End TB Strategy goal to eliminate catastrophic costs of TB-affected households by 2030. Disruptions to TB programs and healthcare services due to COVID-19 could potentially prolong diagnostic delays and worsen TB treatment adherence and outcomes. The economic recession caused by the pandemic could significantly impact household financial capacity because of the reduction of income and the rise in unemployment rates. All of these factors increase the risk of TB incidence and the gravity of economic impact on TB-affected households, and hamper efforts to eliminate catastrophic costs and control TB. Therefore, efforts to eliminate the incidence of TB-affected households facing catastrophic costs will be very challenging. Because financial constraint plays a significant role in TB control, the improvement of health and social protection systems is critical. Even before the pandemic, many TB-high-burden countries (HBCs) lacked robust health and social protection systems. These challenges highlight the substantial need for a more robust engagement of patients and civil society organizations and international support in addressing the consequences of COVID-19 on the control of TB.
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Affiliation(s)
- Ahmad Fuady
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Tanja A. J. Houweling
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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21
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Carter DJ, Pedrazzoli D. Mitigating costs for people living with TB: from measurement to action. Public Health Action 2020; 10:84. [PMID: 33134118 PMCID: PMC7577006 DOI: 10.5588/pha.20.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- D J Carter
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - D Pedrazzoli
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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22
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Huang Y, Huang J, Su X, Chen L, Guo J, Chen W, Zhang L. Analysis of the economic burden of diagnosis and treatment on patients with tuberculosis in Bao'an district of Shenzhen City, China. PLoS One 2020; 15:e0237865. [PMID: 32866187 PMCID: PMC7458315 DOI: 10.1371/journal.pone.0237865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/04/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Illness-related costs experienced by tuberculosis patients produce a severe economic impact on households, especially poor families. Few studies have investigated the full costs, including direct and indirect costs, at the patient and household levels in south-east China. METHODS A case follow-up study was conducted in the Bao'an district of Shenzhen City, China. Eligible new and previously treated individuals with pulmonary tuberculosis (TB) during January 1st 2013 to June 30th 2013 were enrolled. Medical and non-medical costs as well as income loss were calculated in diagnosis and treatment periods, respectively. Factors associated with costs due to TB diagnosis, treatment and TB care (diagnosis + treatment) were explored respectively with a linear regression model. RESULTS Of the total 514 TB patients enrolled, 95% were from the migrant population, and 65% were males, with a mean age of 32.25 (±10.11). The median costs due to TB diagnosis and TB treatment were 79 United States dollar (USD), 748USD (6.2897 China Yuan (CNY) = 1USD, 2013) per patient, respectively. The median costs due to TB care (diagnosis and treatment) per patient was 1218USD, corresponding to 26% of patients' annual income pre-illness. Those who visited more times to health facilities, hospitalized, received higher education, or occupied in national civil servant/services/retired staff might expense more before diagnosis. Costs due to TB treatment was significantly higher among migrant patients, sputum smear positive patients, and widowed/divorced population. Factors associated with less total costs were native patients, fewer times of visiting to health-care facilities and those with no hospitalization history due to TB. CONCLUSIONS Although a free TB control policy is in force, patients with TB are still facing a heavy economic burden. More available interventions to reduce the financial burden on tuberculosis patients are urgently needed.
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Affiliation(s)
- Yixiang Huang
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | | | - Xiaoting Su
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Liang Chen
- Centre for Tuberculosis Control of Guangdong Province, Guangzhou, China
| | - Jianwei Guo
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Weiqing Chen
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- * E-mail:
| | - Lingling Zhang
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts, Boston, United States of America
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Shin H, Ngwira LG, Tucker A, Chaisson RE, Corbett EL, Dowdy D. Patient-incurred cost of inpatient treatment for Tuberculosis in rural Malawi. Trop Med Int Health 2020; 25:624-634. [PMID: 32034984 PMCID: PMC7658961 DOI: 10.1111/tmi.13381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation. METHODS We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279). CONCLUSION Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.
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Affiliation(s)
- Hyejeong Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucky G. Ngwira
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, UK
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth L Corbett
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Erlinger S, Stracker N, Hanrahan C, Nonyane B, Mmolawa L, Tampi R, Tucker A, West N, Lebina L, Martinson N, Dowdy D. Tuberculosis patients with higher levels of poverty face equal or greater costs of illness. Int J Tuberc Lung Dis 2019; 23:1205-1212. [PMID: 31718757 PMCID: PMC6890494 DOI: 10.5588/ijtld.18.0814] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
SETTING: Fifty-six public clinics in Limpopo Province, South Africa.OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index.DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score (a 12-item household-level index), with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, human immunodeficiency virus status and travel time.RESULTS: Among 323 participants, 108 (33%) were 'deprived' (deprivation score >0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95%CI 0.97-1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00-1.40), but lower by a factor of 0.54 with each quintile of lower self-reported income (higher poverty, 95%CI 0.46-0.62).CONCLUSION: Individuals experiencing multidimensional poverty and the cost of tuberculosis illness in Limpopo, South Africa faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.
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Affiliation(s)
- S. Erlinger
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - N. Stracker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - C. Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - B.A.S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - L. Mmolawa
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - R. Tampi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - A. Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - N. West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - L. Lebina
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - N.A. Martinson
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - D. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
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