Catastrophic costs and social sequels due to tuberculosis diagnosis and treatment in Brazil

Guidoni, Leticia Molino; Zandonade, Eliana; Fregona, Geisa; Negri, Letícya dos Santos Almeida; Oliveira, Sandra Maria do Valle Leone de; Prado, Thiago Nascimento do; Sales, Carolina Maia Martins; Coimbra, Raisa da Silveira; Galavote, Heletícia Scabelo; Maciel, Ethel Leonor Noia

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Epidemiologia e Serviços de Saúde

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ORIGINAL ARTICLE • Epidemiol. Serv. Saúde 30 (3) • 2021 • https://doi.org/10.1590/S1679-49742021000300012 copy

Catastrophic costs and social sequels due to tuberculosis diagnosis and treatment in Brazil^* * Article derived from the doctoral thesis entitled 'Impact of catastrophic costs on the treatment of patients with tuberculosis in five regions of Brazil', submitted by Leticia Molino Guidoni to the Postgraduate Program in Collective Health of the Federal University of Espírito Santo, on August 10, 2020.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the impact of catastrophic costs on unfavorable tuberculosis treatment outcomes.

Methods:

This was a prospective cohort study, conducted in five Brazilian state capitals (Manaus, Recife, Vitória, Campo Grande and Porto Alegre) from June 2016 to July 2018. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (95%CI).

Results:

Of the 350 participants, 310 were included, of whom 30 presented unfavorable outcomes. Catastrophic cost (OR=2.53 -95% CI 1.13;5.67) and divorce (OR=5.29 -95% CI 1.39;20.05) increased the chances of unfavorable outcomes.

Conclusion:

Financial difficulties during tuberculosis treatment may impair its outcome. Catastrophic cost and divorce were determining factors for treatment outcomes.

Keywords:
Tuberculosis; Therapeutics; Costs and Cost Analysis; Cohort Studies; Socioeconomic Factors; Brazil

Variables	N (%) Total	N (%) Without catastrophic costs	N (%) With catastrophic costs
Sex
Male	226 (65)	132 (58)	94 (42)
Female	124 (35)	73 (59)	51 (41)
Schooling (years of study)
0-8	173 (49)	82 (47)	91 (53)
>8	177 (51)	123 (69)	54 (31)
Age (years)
18-39	165 (47)	90 (55)	75 (45)
≥40	182 (52)	113 (62)	69 (38)
Not informed	3 (1)	2 (67)	1 (33)
Race/skin color
White	91 (26)	59 (65)	32 (35)
Non-white	257 (73)	145 (56)	112 (44)
Not informed	2 (1)	1 (50)	1 (50)
Head of the family with TB
Yes	162 (46)	86 (53)	76 (47)
No	188 (54)	119 (63)	69 (37)
Formal job
Yes	139 (40)	105 (76)	34 (24)
No	211 (60)	100 (47)	111 (53)
Absence from work or studies
Yes	218 (62)	104 (48)	114 (52)
No	126 (36)	96 (76)	30 (24)
Not informed	6 (1)	5 (83)	1 (18)
Health insurance
Yes	73 (21)	62 (85)	11 (15)
No	277 (79)	143 (52)	134 (48)
Types of tuberculosis (TB)
Pulmonary	263 (75)	161 (61)	102 (39)
Extrapulmonary	87 (25)	44 (51)	43 (49)
Phases of treatment
Intensive	98 (28)	56 (57)	42 (43)
Continuation	252 (72)	149 (59)	103 (41)
HIV^a
Positive	60 (17)	26 (43)	34 (57)
Negative	241 (69)	149 (62)	92 (38)
Untested/unknown	49 (14)	30 (61)	19 (39)
Hospitalization
Yes	140 (40)	65 (46)	75 (54)
No	210 (60)	140 (67)	70 (33)
Previous TB treatment
Yes	60 (17)	30 (50)	30 (50)
No	290 (83)	175 (60)	115 (40)
Initial care
Public	314 (90)	180 (57)	134 (43)
Private	22 (6)	18 (82)	4 (18)
Others	14 (4)	7 (50)	7 (50)
Comorbidities
Yes	142 (41)	76 (54)	66 (46)
No	208 (59)	129 (62)	79 (38)
Social sequel
Yes	230 (66)	123 (53)	107 (47)
No	120 (34)	82 (68)	38 (32)
School dropout
Yes	5 (1)	3 (60)	2 (40)
No	345 (99)	202 (59)	143 (41)
Job abandonment
Yes	98 (28)	40 (41)	58 (59)
No	252 (72)	165 (65)	87 (35)
Divorce
Yes	17 (5)	8 (47)	9 (53)
No	333 (95)	197 (59)	136 (41)
Disturbed sex life
Yes	10 (3)	7 (70)	3 (30)
No	340 (97)	198 (58)	142 (42)
Child got sick
Yes	4 (1)	3 (75)	1 (25)
No	346 (99)	202 (58)	144 (42)
Moved away from people
Yes	95 (25)	-	95 (100)
No	255 (73)	120 (47)	135 (53)
Depression
Yes	10 (3)	7 (70)	3 (30)
No	340 (97)	198 (58)	142 (41)
Experience of prejudice due to tuberculosis
Yes	17 (5)	12 (71)	5 (29)
No	333 (95)	193 (58)	140 (42)
Other social sequels
Yes	128 (37)	78 (61)	50 (39)
No	222 (63)	127 (57)	95 (43)
Household’s financial condition before TB episode
Poor	101 (29)	33 (33)	68 (67)
Non-poor	249 (71)	172 (69)	77 (31)
Household’s financial condition after TB episode
Poor	138 (39)	54 (39)	84 (61)
Non-poor	212 (61)	151 (71)	61 (29)
Household income change after TB episode
Yes	40 (11)	22 (55)	18 (45)
No	310 (89)	183 (59)	127 (41)
Total	350 (100)	205 (59)	145 (41)

Variables	Treatment outcome		Crude odds ratio (95%IC ^a )		Adjusted odds ratio (95%IC ^a )
Variables	Favorable (%)	Unfavorable (%)	Crude odds ratio (95%IC ^a )	p-valor	Adjusted odds ratio (95%IC ^a )	p-value^b
Distal level: sociodemographic variables
Sex
Male	182 (91)	18 (9)	0.80 (0.35;1.92)	0.586^d	-
Female	98 (89)	12 (11)
Schooling (years of study)
0-8	145 (91)	14 (9)	1.22 (0.53;2.82)	0.594^d	-
>8	135 (89)	16 (11)
Age (years)
18-39	135 (91)	14 (9)	1.06 (0.46;2.45)	0.872^d	-
≥40	145 (90)	16 (10)
Race/skin color
White	70 (90)	8 (10)	0.92 (0.37;2.51)	0.859^d	-
Non-white	208 (90)	22 (9%)
Head of the family with tuberculosis
Yes	122 (90)	14 (10)	1.13 (0.492.58)	0.745^d	-
No	158 (91)	16 (9)
Formal job
Yes	112 (93)	9 (7)	1.55 (0.65;3.99)	0.286^d	-
No	168 (89)	21 (11)
Job abandonment or school dropout
Yes	169 (88)	22 (12)	1.98 (0.78;5.69)	0.121^d	-
No	107 (94)	7 (6)
Health insurance
Yes	61 (92)	5 (8)	0.71 (0.20;2.02)	0.515^d	-
No	219 (90)	25 (10)
Intermediate level: clinical information regarding the current TB treatment and changes in family during TB episode variables
Types of tuberculosis
Pulmonary	208 (90)	23 (10)	1.13 (0.44;3.27)	0.776^d	-
Extrapulmonary	72 (91)	7 (9)
Phases of treatment
Intensive	75 (88)	10 (12)	1.36 (0.54; 3.22)	0.445^d	-
Continuation	205 (91)	20 (9)
HIV^c
Positive	50 (93)	4 (7)	0.69 (0.16;2.16)	0.616^e	-
Negative	190 (90)	22 (10)
Hospitalization
Yes	173 (91)	17 (9)	1.23 (0.52;2.82)	0.584^d	-
No	107 (89)	13 (11)
Previous TB treatment
Yes	43 (81)	10 (19)	2.75 (1.07;6.66)	0.013^d	2.34 (0.99;5.53)	0.051
No	237 (92)	20 (8)			1.00
Initial care
Public	254 (91)	25 (9)	1.19 (0.12;5.52)	0.686^e	-
Private	17 (89)	2 (11)
Comorbidities
Yes	119 (91)	12 (9)	0.9 (0.38;2.06)	0.792^d	-
No	161 (90)	18 (10)
Social sequel
Yes	182 (90)	21 (10)	1.25 (0.52;3.23)	0.584^d	-
No	98 (92)	9 (8)
School dropout
Yes	5 (100)	-	0 (0.00;7.2)	0.599^e	-
No	275 (90)	30 (10)
Job abandonment
Yes	80 (86)	13 (14)	1.91 (0.81;4.38)	0.094^d	-
No	200 (92)	17 (8)
Divorce
Yes	8 (67)	4 (33)	5.23 (1.06;21.00)	0.02^e	5.29 (1.39;20.05)	0.014
No	272 (91)	26 (9)			1.00
Disturbed sex life
Yes	10 (100)	-	0 (0.00;3.54)	0.606^e	-
No	270 (90)	30 (10)
Child got sick
Yes	4 (100)	-	0 (0.00;9.14)	0.664^e	-
No	276 (90)	30 (10)
Moved away from people
Yes	72 (92)	6 (8)	0.72 (0.23;1.91)	0.493^d	-
No	208 (90)	24 (10)
Depression
Yes	9 (100)	-	0 (0.00;3.96)	0.395^e	-
No	271 (90)	30 (10)
Experience of prejudice due to tuberculosis
Yes	15 (94)	1 (6)	0.60 (0.01;4.25)	0.528^e	-
No	265 (90)	29 (10)
Other social sequels
Yes	102 (92)	8 (7)	0.63 (0.23;1.54)	0.288^d	-
No	178 (89)	22 (11)
Proximal level: financial variables
Catastrophic cost
Yes	109 (85)	19 (15)	2.70 (1.16;6.54)	0.010^d	2.53 (1.13;5,67)	0,023
No	171 (94)	11 (6)			1,00
Household financial condition before tuberculosis episode
Poor	74 (85)	13 (15)	2.12 (0.90;4.89)	0.050^d	-
Non-poor	206 (92)	17 (8)
Household financial condition after tuberculosis episode
Poor	104 (87)	16 (13)	1.93 (0.84;4.46)	0.084^d	-
Non-poor	176 (93)	14 (7)
Household income change after tuberculosis episode
Yes	33 (92)	3 (8)	0.83 (0.15;2.94)	0.529^e	-
No	247 (90)	27 (10)
Total	280 (90)	30 (10)

Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil SRTVN Quadra 701, Via W5 Norte, Lote D, Edifício P0700, CEP: 70719-040, +55 61 3315-3464, Fax: +55 61 3315-3464 - Brasília - DF - Brazil
E-mail: ress.svs@gmail.com

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[1] Correspondence: Leticia Molino Guidoni - Rodovia Governador Mário Covas, Km 60 - Bairro Litorâneo, São Mateus, ES, Brasil. Postcode: 29932-540.E-mail: leticiaguidoni@hotmail.com