Non-health system related factors affecting tuberculosis treatment outcomes : a case-control study Umgungundlovu Health District.
KwaZulu-Natal province records the highest number of tuberculosis cases diagnosed in the country, but less than 50% of these were cured in 2008, and fewer in those from rural areas and informal settlements where inadequate health care continues. HIV and AIDS associated tuberculosis frequently require labour-intensive methods of monitoring and combating for any success to be achieved. The socio-economic context wherein these diseases occur further limit their control. The low proportion of tuberculosis patients currently with successful treatment outcomes in Umgungundlovu Health District makes essential an in-depth investigation to establish the factors that are associated with these poor outcomes. This study investigates the factors affecting the current poor treatment outcomes in new patients with tuberculosis in a high disease burden district of KwaZulu-Natal in 2011. Methods A retrospective case-control study was conducted comprising 300 adult cases of tuberculosis who failed to complete 6 months of ambulant therapy and 300 frequency matched controls who completed therapy. A random sample of 15 primary health care clinics was selected from where consecutive cases and controls were selected with probability proportional to the number of tuberculosis patients seen at the clinic. Data was extracted from patient records and interviews. Processed data was analysed to identify risk associations using multivariate logistic regression. Results After adjusting for confounding statistically significant risk factors associated with poor tuberculosis treatment outcomes were unemployment (Odds Ratio (OR) 16.0; 95% CI: 6.7 to 37.8); living in a rural area (OR 14.3; 95% CI: 1.1 to 18), distance from home to clinic (OR 1.4; 95% CI: 1.3 to 1.6), living with HIV (OR 2.3; 95% CI: 1.1 to 4.7) and being very ill (OR -5.0; 95% CI: 2.1 to 11.9). Discussion The principal findings are that non-adherence to TB treatment is significantly associated with a number of non-health systems issues. Determinants of poor TB treatment outcomes in patients receiving six-month ambulatory care are diverse and multifactorial. After adjusting for confounding variables, unemployment, distance from patient home to the clinic, living with HIV and being very ill during TB therapy remained significantly associated with a poor TB treatment outcome. Conclusions Although determinants of poor tuberculosis treatment outcomes in patients receiving six-month ambulatory care are diverse and multifactorial, poor tuberculosis treatment outcomes are significantly associated with identifiable factors independent of the health system. Rigorous intervention strategies should prioritize at least these five major risk factors. Recommendations The TB control programme should go beyond the health systems issues to include inter-sectoral collaboration to address socio-economic and other non-health system barriers to adherence to TB treatment. Further research is recommended in this field.