Social determinants of nonadherence to tuberculosis treatment in Buenos Aires, Argentina

Herrero, Maria Belen; Arrossi, Silvina; Ramos, Silvina; Braga, Jose Ueleres

doi:10.1590/0102-311X00024314

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ARTICLE • Cad. Saúde Pública 31 (9) • Sept 2015 • https://doi.org/10.1590/0102-311X00024314 copy

Social determinants of nonadherence to tuberculosis treatment in Buenos Aires, Argentina

Determinantes sociales de la no adherencia al tratamiento de la tuberculosis en Buenos Aires, Argentina

Determinantes sociais da não-adesão ao tratamento de tuberculose em Buenos Aires, Argentina

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study aimed to identify the individual and environmental determinants of nonadherence to tuberculosis (TB) treatment in selected districts in the Buenos Aires Metropolitan Area, in Argentina. We conducted a cross-sectional study using a hierarchical model. Using primary and secondary data, logistic regression was performed to analyze two types of determinants. The likelihood of nonadherence to treatment was greatest among male patients. The following factors led to a greater likelihood of nonadherence to treatment: patients living in a home without running water; head of household without medical insurance; need to use more than one means of transport to reach the health center; place of residence in an area with a high proportion of households connected to the natural gas network; place of residence in an area where a large proportion of families fall below the minimum threshold of subsistence capacity; place of residence in an area where a high proportion of households do not have flushing toilets and basic sanitation. Our results show that social and economic factors – related to both individual and environmental characteristics – influence adherence to TB treatment.

Tuberculosis; Medication Adherence; Epidemiologic Factors; Cross-sectional Studies

Characteristics	First level of analysis (personal characteristics)
	Adherent		Nonadherent		Total
	n	%	n	%	n	%
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
Received sufficient information about the disease and the treatment
Yes	83	97.7	33	86.8	116	94.3
No	2	2.4	5	13.2	7	5.7
Total	85	100.0	38	100.0	123	100.0
Was granted leaves of absence from work to visit the health center
Yes	81	95.3	29	76.3	110	89.4
No	4	4.7	9	23.7	13	10.6
Total	85	100.0	38	100.0	123	100.0
Difficulties in cost of transportation
No	46	55.4	12	32.4	58	48.3
Yes	37	44.6	25	67.6	62	51.7
Total	83	100.0	37	100.0	120 ***	100.0
Difficulties with transportation time
No	65	78.3	24	64.9	89	74.2
Yes	18	21.7	13	35.1	31	25.8
Total	83	100.0	37	100.0	120 ***	100.0
Number of means of transport used to visit the health center
One	64	84.2	24	70.6	88	80.0
More than one	12	15.8	10	29.4	22	20.0
Total	76	100.0	34	100.0	110 #	100.0
TB/HIV co-infection
No	83	97.7	35	92.1	118	95.9
Yes	2	2.35	3	7.9	5	4.1
Total	85	100.0	38	100.0	123	100.0
Distance form health center
Less than 800m	2	2.4	2	5.3	4	3.3
Over 800m	83	97.7	36	94.7	119	96.8
Total	85	100.0	38	100.0	123	100.0
Adequate knowledge of when treatment is to be concluded
Yes	31	36.5	9	23.7	40	32.5
No	54	63.5	29	76.3	83	67.5
Total	85	100.0	38	100.0	123	100.0

Characteristics	Second level of analysis (environmental characteristics related to place of residence)
	Adherent		Nonadherent		Total
	n	%	n	%	n	%
Condition of street lighting
Good	59	69.4	20	47.4	79	65.2
Bad	26	30.6	18	52.6	44	35.8
Total	85	100.0	38	100.0	123	100.0
Natural gas network
In good condition	50	58.8	28	73.7	78	63.4
In bad condition	35	41.2	10	26.3	45	36.6
Total	85	100.0	38	100.0	123	100.0
Subsistence capacity
Below threshold	54	63.5	16	42.1	70	56.9
Above threshold	31	36.5	22	57.9	53	43.1
Total	85	100.0	38	100.0	123	100.0
Inactive population
Lower subset	39	45.9	23	60.5	62	50.4
Upper subset	46	54.1	15	39.5	61	49.6
Total	85	100.0	38	100.0	123	100.0
Flushing toilet and basic sanitation
Upper subset	37	43.5	11	29.0	48	39.0
Lower subset	48	56.5	27	71.1	75	61.0
Total	85	100.0	38	100.0	123	100.0
Self-employed workers
Lower subset	48	56.5	16	42.1	64	52.0
Upper subset	37	43.5	22	57.9	59	48.0
Total	85	100.0	38	100.0	123	100.0
Completed primary education
Upper subset	44	51.8	27	71.1	71	57.7
Lower subset	41	48.2	11	29.0	52	42.3
Total	85	100.0	38	100.0	123	100.0

Characteristics	%	Bivariate analysis			Multivariate analysis
Characteristics	%	OR crude	95%CI	p-value	OR adjusted	95%CI	p-value
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

Characteristics	%	Bivariate analysis			Multivariate analysis
Characteristics	%	OR crude	95%CI	p-value	OR adjusted	95%CI	p-value
Condition of street lighting
Good	47.4	1.00
Bad	52.6	2.04	0.9-4.5	0.075
Natural gas network
In good condition	73.7	1.00			1.00
In bad condition	26.3	0.51	0.2-1.1	0.117	0.25	0.1-0.7	0.012
Subsistence capacity
Below threshold	42.1	1.00			1.00
Above threshold	57.9	2.39	1.1-5.2	0.028	3.40	1.4-8.5	0.007
Inactive population
Lower subset	60.5	1.00			1.00
Upper subset	39.5	0.55	0.3-1.2	0.135	0.31	0.1-0.8	0.022
Self-employed workers
Lower subset	42.1	1.00			1.00
Upper subset	57.9	1.78	0.8-3.9	0.143	2.84	1.1-7.7	0.04
Flushing toilet and basic sanitation
Upper subset	29.0	1.00			1.00
Lower subset	71.1	1.89	0.8-4.3	0.128	3.39	1.2-9.4	0.018
Completed primary education
Upper subset	71.1	1.00
Lower subset	29.0	0.44	0.2-1.0	0.048

Characteristics	Hierarchical model
Characteristics	%	OR adjusted	95%CI	p-value
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

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[1] Correspondence. M. B. Herrero. Centro de Estudios de Estado y Sociedad. Sanchez de Bustamante 27, Buenos Aires 1173, Argentina.mbelen.herrero@gmail.com