| BackgroundChina is one of the three countries which have the highest burden of drug-resistant tuberculosis(DR-TB),and DR-TB is a severe infectious disease that threatening public health.The treatment of DR-TB has long period and many side effects,and the financial burden caused by it is heavy and the cure rate is low.As a result,DR-TB patients have low treatment adherence rate and poor treatment outcomes.Previous studies for influencing factors of DR-TB focus on individual-related factors,such as socio-demographic characteristics,disease-related knowledge and adverse effects,there is a lack of researches which take social structural factors into consideration.ObjectiveThis research aims at understanding the treatment adherence,treatment outcomes and the relationships between them and their influencing factors.Based on the social determinants of health conceptual framework proposed by the World Health Organization(WHO),we explored the effects of circumstances of daily life and social structural drivers on treatment adherence and treatment outcomes of DR-TB patients,in order to provide scientific suggestions for treatment outcomes improvement and promotion of DR-TB management in China.MethodsThe study is supported by National Natural Science Foundation of China(grant number:71804092).As an ambispective cohort study,it finished the baseline and one-year follow-up investigations in 9 cities in Shandong and Zhejiang province and the follow-up investigations were conducted quarterly.We collected the basic information of DR-TB patients,treatment costs,national insurance reimbursement,treatment behavioural options,psychosocial support and treatment adherence in baseline investigation.And in follow-up investigation,the information of recent treatment costs,reimbursement,times and contents of follow-up conducted by community healthcare staffs,treatment adherence and treatment outcomes were added in questionnaire to comprehend the treatment conditions of DR-TB patients.We also took half-structural interviews in baseline phase to understand the health financing,disease burden of DR-TB patients,patient management in community level and difficulties in DR-TB treatment period,and at the end of follow-up phrase we interviewed officers in local center for Disease Control and Prevention(CDC)to figure out the reasons of problems found in follow-up investigation.General statistical descriptive indicators such as mean,standard deviation,chi-square test and t test were used to describe and analyze the factors of demographic characteristics,circumstances of daily life and social structural drivers.Multiple linear regression and Logistic regression analysis were used to evaluate the impacts of circumstances of daily life and social structural factors on treatment adherence and treatment outcomes of DR-TB patients.Excel 2020 and SPSS 22 were used as main software to analyze data.ResultsThere were 70.3%(194)DR-TB patients in 276 participants who got positive treatment outcomes.The treatment success rate was 43.1%,which was the sum of cure(26.1%)and treatment completion(17.0%).There were 82(29.71%)patients who got negative treatment outcomes,50.0%of them got treatment failure,41.5%patients lost to follow-up and 8.5%patients died.The average treatment adherence rate was 95.0%through the whole treatment period.The treatment adherence rate of patients who got positive treatment outcomes was over 98.0%,but treatment adherence rate of patients who got negative treatment outcomes collapsed from 92.8%in baseline to 65.2%at the end of the follow-up period,thus the polarization of treatment adherence was observed in DR-TB patients whose treatment outcomes were different.The multi-factor analysis showed that the factors of daily life and social structure would affect the treatment adherence and treatment outcomes of DR-TB patients.The social determinants of health of treatment adherence included gender(P=0.011),education(P=0.035),occupation(P<0.001)and social support(P=0.046)as daily life factors,and medical insurance reimbursement(P=0.035)and treatment subsidies(P=0.030)as social structural factors.It meant the patients who were female,educated above middle school,not farmers or migrant workers,had higher social support scores,higher reimbursement level and more subsidies showed better treatment adherence.The social determinants of health of treatment outcomes included treatment adherence(OR=29.16),treatment duration(OR=2.57),the intake of protein(OR=2.83)and disease burden(OR=3.02)as daily life factors,and the triad management system(OR=4.51)as social structural factors.It meant the patients who had better treatment adherence,longer treatment period,less disease burden,took high-quality protein and were under TB triad management system would more possibly got positive treatment outcomes.The available access to anti-TB medicine in COVID-19 pandemics was the social determinant of both treatment adherence and treatment outcomes.According to interview,unaffordable treatment and side-effects of medicine were the main difficulties for patients.Sometimes the free anti-TB drugs were in short supply,the poor access to anti-TB drugs in COVID-19 pandemic was found and the stigma and discrimination depressed patients’ treatment motivation.And primary healthcare institutions were the weakest link in TB triad management system.Conclusion and suggestionGreat division of treatment adherence was shown in patients with different treatment outcomes.The treatment success rate was only 43.1%,lower than the global treatment success rate(57%),reported by the World Health Organization in 2020.The heavy financial burden,social discrimination,great gap in patient management and dysfunctional primary healthcare system were observed.The TB triad management system,which is composed of TB designated hospitals,CDCs and primary healthcare institutions,should be applied in more cities.The functions of CDCs in overall planning and coordination should be encouraged to strengthen the flexibility of healthcare system in response of public health emergency and anti-TB medicine supply.And the medical insurance reimbursement and social support should be enhanced. |
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