Gender Differences in Utilization Pattern and Outcome of Respiratory Tuberculosis
1-4 Community Medicine Department, Faculty of Medicine, Alexandria University.
5 Tuberculosis Control Programme, Alexandria Directorate of Health Affairs, Ministry of Health.
Abstract
INTRODUCTION:
Until recently, medical research and health program policy makers have assumed that the effects of most diseases were similar for both men and women, and any differences were due directly to biological differences, particularly the reproductive aspects of women’s health. As the full effects on women of the HIV epidemic were appreciated, the gender inequalities inherent in many tropical diseases became a subject of study (1).
The concept of gender describes those characteristics of men and women that are socially constructed as well as biologically determined, incorporating the behaviours, expectations and roles which result from the different perceptions attributed to men and women in a particular cultural setting (2-4).
Gender analysis in health (5) is concerned with asking how and why inequity occurs in health; in other words, a gendered analysis in health takes the emphasis away from questions of organic / biological causality and concentrates on explaining the differential constraints experienced by women and men in access to health and health care. The gender perspective facilitates a more contextualized understanding of differences between women and men in relation to: rates of and vulnerability to infection; differences in access to and use of available health care resources; differences in the effect of the social meanings, especially stigmatization of infectious diseases; the effects of disease on women as primary health care providers in their homes; and key dimensions of structural difference based on factors such as age and social status (including but not limited to economic status / class ).
The magnitude of the global tuberculosis epidemic is enormous. About a third of the world’s population is infected with Mycobacterium tuberculosis. In 1998, about three-quarters of a million women died of TB, and over three million contracted the disease, accounting for about 17 million disability adjusted life years (DALY). It is the greatest single infectious cause of death in women of reproductive age worldwide (6, 7).
The social and economic costs of tuberculosis disease, and related deaths, among women affect not only individuals, but also the welfare of families and communities.
Literature on gender and TB is scanty. Only a few concise reviews on epidemiological and sociocultural gender differentials are available (8, 9). Worldwide, more men than women are diagnosed with TB. Tuberculosis programs in many parts of the world register for treatment up to three times more men than women.
Some studies indicate that women may have higher rates of progression from infection to disease and a higher case fatality in their early reproductive ages. It is not clear to what extent these differences result from biological, geographic, socio-cultural contexts, under-recognition of TB among women due to poor access to care or from health service factors (5).
Higher rates reported for TB in young and early middle-aged women in industrialized settings earlier in the past century raise a question whether under-detection of women TB patients in poor countries may be due to various problems of access to care. If gender inequalities in TB are due to problems of access and under utilization of available services, these problems should be clarified and remedied by TB programmes. To do so, it is essential to determine the extent to which the observed sex differences in tuberculosis notification rates in low- income countries arise from distinctive obstacles faced by men and women (5).
Despite the efforts of the Egyptian National Tuberculosis Programme (NTP), TB remains a major public health problem in Egypt.
Although a substantial reduction in the magnitude of TB problem after the application of DOTS strategy has been achieved generally, the cure rate target (> 85%) specified nationally and globally has not been achieved yet (the cure rate was 77% in 1999) (3). National NTP surveys in most governorates have documented excess of male over female TB cases reported each year. In Alexandria, the male to female ratio of registered TB cases varied between 2. 6: 1 (in 1997) to 1.
7: 1 (in 2001). Also, women were more likely to have poorer treatment outcomes and higher case fatality compared to men. It was evident that women confront more barriers than men in accessing TB care services. The reasons for this difference are unclear. Yet, research is lacking to explain the impact of gender inequalities in access to care.
JUSTIFICATION:
The impact of gender on health has been largely ignored, and in TB research and control effort, gender was not just missing, it was also considered unnecessary. However, as TB re-emerged, control efforts have begun to focus on the role of gender for this disease. Traditionally, women have had to face much greater health risks; confront many more constraints and make do with much fewer opportunities in trying to solve their health needs than men. Therefore, efforts were done in the present work to identify and address gender differentials in TB control.
As a contribution to an explanatory framework for gender differences in access to and use of TB services, and in collaboration with the providers of the National DOTS strategy, the present study was designed and conducted in seven different treatment settings in Alexandria.
The aim of this research was to gain more insight into the gender differences in health seeking and illness behaviour of tuberculosis patients, and to explore and describe the factors that influence men’s and women’s decisions to seek medical care and to stay on regular treatment till they are cured. Terms as ‘case finding’ and ‘compliance’ were reworked into behavioural, social and cultural definitions. The insights gained by this study will hopefully benefit in planning effective gender-sensitive interventions and policies to better control tuberculosis.
AIM OF THE STUDY:
The objectives of the present study were:
1) To determine sex ratio among registered pulmonary TB cases.
2) To describe and compare utilization pattern of tuberculosis services and between male and female TB cases.
3) To describe and compare outcomes of TB treatment between male and female TB cases.
4) To identify factors behind gender differences in health seeking behaviour, diagnostic delay, TB treatment adherence (compliance behaviour) and subsequent treatment outcomes.
SUBJECTS AND METHODS:
Both descriptive and analytic epidemiologic approaches were adopted. A cross-sectional comparative study design was utilized to describe and compare the distribution of the various study variables among male and female TB cases, and to explore the existence of a possible causal association between gender differentials and each of treatment adherence and outcomes.
Having established that gender differentials were associated with the outcome indicators, a cohort study (8 months follow up) was applied to measure the extent to which these factors cause or contribute to the problem (i. e.
to measure the strength of association and to quantify risk).
The study population was all newly diagnosed pulmonary TB cases who commenced on anti-tuberculosis therapy (through the DOTS programme) during the period from December 2001 To November 2002, at the seven chest dispensaries in Alexandria (El-Maa moura, Backus, Moharrem Bey, El-Gom rok, El-Kabbary, Karmouz and El- Am ria). The total number of registered cases was 334. Their records were monthly followed-up for treatment compliance. Patients who have commenced on treatment within the 3 months preceding the study were also included.
Their compliance with treatment prior to the study was assessed by reviewing their records retrospectively. Afterwards, they were followed-up prospectively. Patients were interviewed at the chest dispensary. Those who didn’t show up during the field period, were interviewed at homes according to their recorded addresses.
All treatment control cards for patients treated from March to October 2002, in the seven chest dispensaries under study, were reviewed. A structured interviewing questionnaire was used to collect the following data: Demographic and socio-economic background; Patient’s satisfaction with quality of care provided; Patient’s knowledge, attitudes, beliefs, and opinions about tuberculosis; Clinical, microbiological, radiological and treatment data; Monitoring adherence to treatment and the treatment response; and Classification at completion of therapy.
PLAN FOR DATA COLLECTION
Data collectors and field supervisors:
Data collectors were selected according to their previous experience in the field of tuberculosis. Seven nurses and physicians were selected from the chest clinics to collect data from the records as well as for interviewing the patients and collecting the required information. Two field supervisors were regularly monitoring the process of data collection with regard to adequacy and quality. Field supervisors were experienced in field work and data collection. Orientation of the field supervisors about all the procedures of the study was carried out by the principal investigator. Training for data collection was done before any job assignment.
PLAN FOR DATA PROCESSING AND ANALYSIS
Calculation of scores:
The mean percent score was calculated as follows: The score of negative questions was first reversed before addition to its domain. The following equation was used: (score – number of questions) X 100 / (Maximum possible score – number of questions). The calculated domains were: perception about TB, satisfaction with services, communication, family relationship, and impact on reproductive health of women.
Compliance during the period of follow up was calculated as follows:
i) Overall percent of compliance along the follow up period was calculated out of the expected maximum. For drug compliance; the consumed units of treatment was calculated as a percent out of the assigned total units.
ii) Compliance for examination, attending health education session, sputum examination, and chest X-ray was calculated as performing 80% or more of the required.
Drug compliance was calculated as consuming 80% or more of the assigned units during each follow visit.
Design of analysis forms:
The interviewing questionnaire was designed in a format which enables data operators to directly feed the collected data from the formats to the computer without the need to a transfer formats so as to save time, effort, and money. The form was provided with squares beside each variable for entering the value of the variable. The variable number in the format was used as the computer variable number to facilitate data handling. Also most of the questions were closed ended with very few exceptions. This approach was utilized to minimize errors of data entry.
Handling techniques:
The EPI Info Statistical Program was used for tabulation and statistical analysis of the results. Data files were constructed prior to data entry and complete variable and value labeling were selected to facilitate interpretation of the computer output.
The quality of the collected data was reviewed twice weekly by the filed supervisors at the field. Open ended questions were coded with great care to avoid duplication. Data entry verification was performed by determining the number of digits for each variable, studying the frequency of each variable, and cross tabulation of related variables.
Statistical methods used included:
Descriptive measures: frequency, percent, arithmetic mean, and standard deviation.
Statistical tests: included student t- test, Mann Whitney test, Chi square, and multiple logistic regression analysis.
The level of significance selected for this study was the 0. 05 level.
ETHICAL CONSIDERATIONS:
Once approved by WHO, the proposed research has been approved by the Directorate of Health Affairs in Alexandria and TB control Project managers. All participants gave their informed oral consent voluntarily.
The following points were thoroughly clarified to all participants: Purpose of the research, Procedures that will be followed, including the total time involved for the subject, Benefits of the research, separated into “benefits to the subject” and “benefits to others.” Absolute confidentiality of information, and the subject’s right to withdraw from the study at any time without in any way affecting his / her current or future care.
RESULTS:
A total of 334 of TB patients were reported to all health facilities (7 chest dispensaries in Alexandria during the year 2002).
Epidemiological characteristics of tuberculous patients
a- Personal data
Age and sex
Male cases of TB outnumbered female ones (69. 2% compared to 30. 8%) with an overall male to female ratio 2. 24: 1.
Age of TB patients ranged from 14 to 75 years with a mean age of 36.
92 + 14. 581. The mean age of male patients was 36. 52+13. 437 years. This was lower than that of females (37.
77+15. 018 years). However, no significant difference was observed between male and female patients regarding their mean age.
Marital status
Married and widow female TB cases were significantly higher than male cases (61. 2% compared to 57. 6% and 10.
7% compared to only 0. 4% respectively). However, the percentage of single male patients was higher than females (39. 4% compared to 25. 2%). Nearly similar proportions of males and females (2.
6% and 2. 9%) were divorced. A statistical significant difference was observed between males and females as regards marital status where X 32 = 25. 073 (P = 0. 0001).
Place of birth
More male TB patients were born in Alexandria (84.
0% compared to 73. 8% of females). On the other hand, female patients were more likely to be born outside the governorate (26. 2% compared to 16.
0%). The difference observed was statistically significant, where X 12 = 4. 78 (P = 0. 0288).
b- Social characteristics
Educational level
A significant gender difference was observed in the educational level, where X 52 = 16. 432 (P = 0. 01161). More females than males tended to be illiterates (46. 6% compared to 39.
0%), or had obtained primary certificate (15. 5% compared to 9. 1%) or university one (8. 8% compared to 3. 9%). On the other hand, more male patients than females were able to read and write (23.
4% compared to 17. 5%). They also tended to hold either a preparatory certificate (9. 5% compared to 1. 9%), or a secondary one (15. 2% compared to 9.
7%).
Current Job
The majority of female patients were not working (93. 2%), whereas only 24. 6% of male patients were not gainfully employed, where X 62 = 137.
613 (P = 0. 0).
Family head
The majority of male patients (69. 7%) were the sole breadwinners compared to less than a fifth of females (18. 4%). However, the husband was considered as a family head for the majority of female patients (80.
6%). In the minority of both male and female patients (0. 4% and 1. 0%), the father was the head of the family. The difference between both sexes as regards family head is statistically significant (X 22 = 76.
855, P =
31 and P = 0. 758) and also whether income is sufficient to meet the family needs or not (X 12 = 0. 493 (P = 0. 4824).
Habits
– Smoking
Female patients were more likely to be non- smokers (94. 2%) than male patients (18. 6%). On the other hand, male patients were more likely to be current smokers (24. 2% compared to 3. 9%) or used to be (57.
1% compared to 1. 9%). The differences observed were statistically significant, where X 22 = 167. 572 (P = 0. 0001).
– Addiction
Although the majority of male and female patients claimed to be non-addicts (88.
7% and 98. 1%). However, more than one tenth of males (11. 3%) and only 1. 9% of females admitted their addiction. The differences observed were statistically significant, where X 12 = 8.
046 (P = 0. 0046).
c- Housing environment
Type of house
Nearly equal proportions of male and female patients were living in separate houses (87. 0% and 87. 4%). More than one tenth of males (13.
0% compared to 12. 6%) lived in shared houses. No significant differences were observed as regards type of house, where X 12 = 0. 008 (P = 0.
9266).
Number of rooms
Number of rooms of tuberculous patients ranged from 1 to 5 rooms, with a mean number of 2. 883 + 0. 937 rooms. The differences between both sexes as regards number of rooms were statistically insignificant, where X 42 = 2. 603 (P = 0.
6264).
Family size
Family size of TB patients ranged from 1 to 11 persons with a mean of 4. 24 + 1. 84 persons.
The mean family size of females was 4. 54 + 1. 725 persons. This was significantly higher than that for males (4. 05 + 1. 969 persons), where Z = 2.
674 and P = 0. 0075).
Crowding index
Crowding index of the sample ranged from 0. 2-7 persons /room with a mean index of 1.
65 + 1. 061 persons /room. The mean crowding index of female patients was 1. 77 + 1. 054 persons /room. This was significantly higher than that of males (1.
60 + 1. 067 persons /room), where Z = 1. 985 and (P = 0. 0047).
Clinical features of tuberculosis
Table (1) shows the pattern of the disease at the time of interview namely type, diagnosis, treatment regimen, duration and manifestations of tuberculosis.
Table (1): Type and manifestations of tuberculosis at time of interviewing tuberculous male and female patients
Tuberculosis Males Females Total Statistical test (X 2)
No.
% No. % No. %
TypePulmonaryPulmonary & extra pulmonary 2265 97. 82.
2 1003 97. 12. 9 3268 97. 62. 4 0. 171 (0.
6796)
Diagnosis at interview New caseRecurrenceTreatment failure Completing treatment 18728142 80. 912. 16. 10.
9 731776 70. 816. 56. 85. 9 26045218 77. 813.
56. 32. 4 11. 737 (0. 04303)
Treatment regimensIIIIII 1434147 61.
917. 720. 4 561829 54. 417.
528. 1 199597 59. 617. 722.
7 2. 591 (0. 274)
Duration of disease (months) Mean + SD 4. 44 + 6. 20 5.
12 + 4. 73 4. 74 + 5. 67 Z = 1. 586 (0. 1128)
Manifestations
Fever 75 32.
5 36 35. 0 111 33. 2 0. 198 (0.
6563)
Weight loss 192 83. 1 86 83. 5 278 83. 2 0. 007 (0. 9319)
Chest pain 102 44.
2 47 45. 6 149 44. 6 0. 063 (0.
8022)
Dyspnoea 164 71. 0 74 71. 8 238 71. 3 0.
025 (0. 8742)
Urticaria 17 7. 4 6 5. 8 23 6. 9 0. 261 (0.
6091)
Purpura 6 2. 6 15 14. 6 21 6. 3 17. 310 (0. 0003)
Jaundice 10 4.
3 2 1. 9 12 3. 6 1. 172 (0.
2790)
Urinary incontinence 4 1. 7 5 4. 9 9 2. 7 2. 649 (0. 1034)
Significant, P
05.
Pattern of utilization of health care facilities
Receiving treatment in other health facilities:
A minority of both males (6. 1%) and females (8. 7%) received TB treatment in other health facilities in addition to treatment inside chest hospitals and clinics, P = 0. 1674.
Number of hospital admissions:
Number of hospital admission ranged from 0 to 3 with a mean of 0.
548 + 0. 447 time. Males were more frequently once hospitalized (38. 1%) than females (31.
1%), however, more females (5. 8%) than males (2. 6%) were hospitalized twice during the previous year. The total days of hospital admission ranged from 1 to 260 days with a mean of 54. 86 + 53. 56 days.
The mean total days of hospital admission for female patients was 75. 17 + 63. 85 days. This was significantly higher than that of male patients (45. 58 + 46. 28 days), P = 0.
0033.
Factors affecting pattern of utilization of the available services
a) Health seeking behaviour
A significantly higher proportions of female patients (35%) tended to use traditional medicines for treatment of tuberculosis compared to males (24. 2%), P = 0. 04305. Chest clinics, hospitals, and private clinics were the main diagnosing facilities for both males (51.
5%, 32. 5%, and 14. 7% respectively) and females (42. 7%, 20. 4%, and 28. 8%).
These differences were statistically significant, P = 0. 0001.
Chest hospital and chest clinics were the first seemed facilities for higher percentages of male patients (30. 7 % and 52. 8 %) compared to female patients (25. 2 % and 48.
5 %). On the other hand, general hospitals, private clinics and other health facilities were more encountered as seeking behaviour among female patients (3. 9%, 20. 4%, and 1.
9% respectively) compared to males (1. 3%, 14. 7%, and 0. 4% respectively). However, these differences were not statistically significant, P = 0. 1674.
b) Adherence of the patients to treatment, follow up and health education sessions
The majority of tuberculous patients (85%) were adherent to treatment. Females were more active participants than males (86. 4% compared to 84. 4%). However, just less than one six of patients (15%) stopped treatment. More males (10.
8%) compared to 9. 7% of females stopped treatment due to side effects. The difference between males and females regarding adherence to treatment was statistically significant, where (P = 0. 04123). Home visits were done in more-than one sixth of tuberculous patients (18%).
More females (19. 4%) were visited compared to males (17. 3%) However, the difference between males &females was statistically insignificant, P = 0. 06440. The majority of the tuberculous patients (94. 9%) attended regularly the clinic.
However, 5. 1% of them stopped attendance. More females (5. 8%) compared to 4.
9% of males stopped attendance to the clinic. The difference between males and females was statistically insignificant (P = 0. 68303). The majority of the tuberculous patients (92. 5%) did not miss any of health education sessions. However, Just less than a tenth of patients missed some health education sessions.
A significantly higher percentage of females (11. 7%) compared to only 5. 6% of males missed some health education session, where P = 0. 05039.
c) Sources of knowledge about TB
Chest clinic was the main source of knowledge for the majority of both males (74. 4%) and females (69.
0%). More than a tenth of females (11. 6%) compared to 10. 4% of males were informed about tuberculosis through the mass media.
More females (11. 6%) compared to 5. 2% of males were informed about tuberculosis through other patients. Other sources such as private physician and nurses were the sources of knowledge for 10% of males and 7. 8% of females. The differences were statistically insignificant, P = 0.
2948.
d) Diagnosis and treatment delay:
Table (2) illustrates that the delay in diagnosis of tuberculosis ranged from 0 to 4 months with a mean of 2. 185 + 1. 738 months. No statistical significant difference was observed between male and female patients as regards mean duration of diagnostic delay (2.
22 + 1. 86 months compared with 2. 10 + 2. 97 months, P = 0. 3670. The delay in treatment of tuberculosis ranged from 1 to 21 weeks with a mean duration of 1.
33 + 1. 51 weeks. The mean duration of treatment delay for male patients (1. 43 + 1.
69 weeks) was significantly higher than that of females (1. 15 + 1. 32 weeks), where P = 0. 0001. The table indicated that about two thirds (64. 4%) of patients received treatment within the first week of diagnosing the disease.
e) Accessibility to health care facilities
Distance to clinic ranged from 0. 1 to 60 km with a mean of 9. 75 + 10. 76 km and a median of 8. 98 km.
Female patients were living, on the average, 8. 07 + 9. 245 km away from the health service while male patients lived, on the average, 10. 05 + 11. 89 km away from the facility, P = 0. 3230).
About half the patients (52. 4%) were living within a walking distance (
38 + 16. 39 minutes) and female (24. 86 + 22. 26 minutes) patients, P = 0. 8684. Just less than one fourth of males (24.
2%) were reaching the clinic on foot compared with 19. 4% of females. The latter tended to use public transportation slightly more than males (16. 5% compared with 13. 9%). The most common mean of transportation (microbus) was equally utilized by both sexes (55.
4% and 55. 3% respectively), P = 0. 5684.
Table (2): Diagnostic and treatment delay for tuberculous male and female patients
Characteristics Males Females Total Mann Whitney Z
No. % No. % No.
%
Diagnostic delay (months).