| BackgroundDOTS (Directly Observed Treatment, Short-Course) had effectively reduced tuberculosis (TB) prevalence and mortality, but China are still facing challenges in TB control. TB distributes unequally among different areas and populations; TB prevalence is highest in inland areas, median in central areas and lowest in coastal areas. Besides, prevalence in rural areas is higher than that in urban areas. It is emerging that we find out why TB is unbalanced prevailing and continually concentrated in some areas. TB is classically related to poverty. The poor and disadvantaged populations live in poor conditions, which increase their risk of TB infection and disease onset. At the same time they often have difficulties in acquiring qualified health service, thus resulting in a poor treatment outcome. Detection and treatment of TB patients are also influenced by DOTS quality, access to and sustainability of health service. Meanwhile socioeconomic factors could affect disease control, especially infectious disease control, through impact on health service capacity. Therefore, research on TB epidemic should involve social determinants, the provider and the demand side of health service.ObjectivesThe research aims at:1)describing TB epidemic, resources, TB health service providing and TB related knowledge, attitude and practices (KAP) of focus groups in different areas; 2) analyzing the influence and impact of social determinants, health service and health resource, assessing accessibility of TB health care and finally raising evidence for effective strategy and intervention toward TB epidemic.MethodResearch designThe research consists of 4 parts:1) descriptive research of TB epidemic and socioeconomic development by data mining and ecological methods; 2) research of TB control network functioning and TB health service providing through quantitatively describing TB resources and qualitative interview;3) research of TB related KAP in focus groups and TB health service accessibility by cross-sectional study; 4) comprehensive research of influencing factors of TB epidemic using multi-level models.FieldsFour counties in each of Sichuan, Guizhou and Yunnan province (totally 12 counties) were selected as sites, including 2 counties where 1 high TB prevailing sites and 1 relatively low prevailing sites of the same province discovered in the 2010 National TB Epidemiology Survey locates, and 2 neighboring counties of the high prevailing site and low prevailing sites respectively.Data collectionData collection includes collection of historical statistics and field survey. Information of TB notification rate, socioeconomic development, health resource and TB resources between 2001 and 2010 was collected through forms issued to TB staff in sites. Field investigation was conducted during Mar 1st to Dec 31th,2013.1) In-depth interview: administrators of TB programs and health staff in the county-township-village TB control network were in-depth interviewed for TB epidemic, TB resources, TB policy, patterns and problems of TB control, construction and function of the TB control network, and potential factors influencing TB epidemic.2) Questionnaire survey:questionnaires were used to assess key TB messages awareness rate, TB related attitude and parctices, access to TB information of health staff, senior high school students, TB patients and chronic cough patients as well as health-care seeking behavior of TB patient and chronic cough patients.Data analysisGraphics, mean, median and frequency were used to describe quantitative data. Chi-square test and Kruskal-Willis test were used in statistics. Mixed linear model was used as multi-level model. Microsoft Office Excel 2010 and SPSS 17.0 were used in quantitative data analysis (α=0.05). Qualitative data was recorded into Word documents and thematic framework analysis was performed using Maxqda 10.Result1. TB epidemic and socioeconomic development:TB notification rate of sites increased during 2001 and 2007, and most counties had a stable or slowly reducing case notification rate since 2008. The high prevailing site in Guizhou province bore highest TB notification rate, reaching peaking value (254.58 per 100,000) in the year 2008. GDP, per capita GDP, urban per capita disposable income, rural per capita net income had a solid growth during ten years, while practice (assistant) doctors and slightly increased. Notification rate of notifiable infectious diseases declined. High prevailing site present higher case notification rate and lower socioeconomic indicators compared to low prevailing site in the same province. GDP (t=-2.341, P=0.040) and urban per capita disposable income (t=-2.390, P=0.037) were negatively associated with TB notification rate in single factor analysis.2. TB network function and health care capacity:1) TB resources:TB fund in most sites declined after increasing for several years during 2001 and 2010, in which central transfer payment was the main source and international financial aid was reduced. The high prevailing site in Yunnan Province present highest average fund level, the maximum amount was 840,000 per year. Whereas the lowest average fund level was approximately 100,000 per year. The number of TB staff was less than 10 in all sites except one in Guizhou Province. TB staff in four sites present high mobility with an over-ten-person sum of in-flow and out-flow during the ten years. Microscopes and X-ray apparatus had been equipped in all sites for regular sputum smear test and chest X-ray test.2) In-depth interview:in total 6 provincial TB administrator,29 county level TB administrator and 36 medical staff were in-depth interviewed. ①TB epidemic had been stable and slightly decreased in recent years. Symptomless patients and mild cases were increasing. TB in migrants became an extrusive problem. ②TB resource deficiency:county-level TB workers was in shortage and the current staff capacity could not meet demand; giant gap lays in TB fund, in which the central government fund was not sufficient and local fund was rarely put in budget, setting barriers to TB control.③TB strategy:Medical expense besides national TB free treatment policy was included in reimbursement in the new rural cooperative medical care system, effectively reducing economic burden and raising compliance of patients.④problems in TB control:Health staff in township and village level was lacking, which was worsened by the fact that they had limited capacity and high mobility but was given heavy clinical and public health work. The current excitation mechanism to promote case refer was ineffective, and no oversight mechanism toward case report of health care settings had been established. Meanwhile, clinical capacity of county TB dispensary was limited. ⑤TB healthcare:Patient detection was negatively influenced by poor communication inside general hospital, the fact that some patients attending general hospital were not referred to TB dispensaries, and blank patient information in case report. Limited health care capacity of providers leads to non-strict DOTS and poor outcomes. Designated hospital pattern reduced referring procedures and achieve better use of general hospital capacity, whereas problems like realizing TB treatment policy in hospital condition and insufficient patient information sharing between hospitals and TB dispensaries remain to be solved. Loss of follow-up and poor DOTS in migrant patients were common after they came out for work during treatment.⑥Poverty, indirect medical cost, low education level, geographic factors, stigma and local customs were also potential determinants of TB epidemic.3. TB knowledge, attitude, practices and health care accessibility:539, 857,566 and 510 effective questionnaires of health staff, grade 11 students, TB patients and chronic cough patients were collected. ① awareness rate:general awareness rates of core TB related messages were 78.8%,67.7%,70.0% and 61.5% for health staff, grade 11 students, TB patients and chronic cough patients, respectively. General awareness rates of the 4 groups were higher than that of the general population in the 2010 National TB Epidemiology Survey, but still lower than the goal in National TB Project. Awareness rate of TB treatment policy is low in all four groups, only 46.6%,37.2%,44.7% and 31.9% for health staff, grade 11 students, TB patients and chronic cough patients.② Key message scores differed among health staff in different levels (Kruskal-Wallis χ2=13.082, P=0.001); health staff in township and village level scored lower than those in county level.12.4% of the health staff had not been trained for TB. Of those health staff who had treated TB suspects,13.2% empirically prescribed antibiotics,8.3% let TB suspects being treated in hospital. Medical staff knowing designated TB institute were less likely to keep TB suspects in hospital (P=0.017).③ Gender (Kruskal-Wallis χ2=4.518,P=0.034), province (Kruskal-Wallis χ2=63.879, P<0.001)and type of site (Kruskal-Wallis χ2=53.942, P<0.001) were associated with key message scores in senior high school students; male, students in Yunnan Province and students from counties neighboring sites in 2010 National Survey had lower scores. Only 1.8% of the students were not willing to learn TB knowledge; 21.1% would keep away from TB patients. Television, newspapers, oral communication, internet and school education were main source of getting TB knowledge. ④chronic cough patients scored lower than TB patients (Kruskal-Wallis χ2=34.007, P<0.001), patients with lower economic condition scored lower (Kruskal-Wallis χ2=8.375,P=0.039). Leaflet, television, oral communication and bulletin board were main source of TB message among chronic cough patients and TB patients. Frequency of patients with patient delay more than 2 weeks was higher in TB patients (52.7%) than in chronic cough patients (33.7%).52.2%,31.7% and 16.0% of TB patients and chronic cough patients chose village/township institute, county hospital and TB dispensary at first visit respectively. Patients who chose TB dispensary at first visit present higher TB message score (Kruskal-Wallis χ2=13.217, P<0.001). Doctor delay rate of TB patients was 35.6%, and patients choosing village/township institute, county hospital and TB dispensary at first visit had different doctor delay rate (40.0%,42.0% and 11.3%, respectively,χ2=29.128, P<0.001).16.4% of TB patients were self-supervised during treatment; 13.2% of patients who had adverse reaction took drug irregularly or stopped drug intake.32.0% of TB patient felt economic pressure in treatment; 23.1%,17.1% and 21.2% of TB patient felt exclusion, family status decreasing and social status decreasing, respectively.4. multivariable analysis:socioeconomic development (β=-0.315, P=0.013), notification rate of notifiable infectious diseases (P=0.307, P=0.023), TB staff type (full-time and low-flowing vs. full-time and high-flowing,β=-0.426, P=0.037; part-time and low-flowing vs. full-time and high-flowing,β=-0.917, P=0.017), close attention of local government (β=0.780,P<0.001) were associated with TB notification rate. Poor socioeconomic development, poor health environment, frequent flowing of TB staff and limited concern of local government were potential risk factors of TB epidemic.ConclusionLimited TB human resources, fund deficiency, low capacity of health staff in grass roots, ineffective Public-Private Mix and migration were barriers in TB manage and health service providing. Economic burden of TB patients was reduced due to NCMS reimbursement of medical expense. Poverty, educational level, geographic condition, stigma and customs were also socioeconomic factors influencing TB patient manage and TB epidemic. Deficiency in TB knowledge of health staff limited their capacity in case detection and in-time patient refer. TB related KAP needs to be improved in all groups, especially chronic cough patients who were considered as potential TB patients. Accessibility of TB health care is limited, with quite a few of patients presenting delayed healthcare seeking and delayed diagnosis. In performance of TB related health education and health promotion, acceptance of different media and methods in different groups needs to be considered.Poor socioeconomic development, poor health environment, frequent flowing of TB staff and limited concern of local government were potential risk factors of TB epidemic. Balanced socioeconomic development, health improve, intensified government concern and better human resource distribution could be propitious to TB epidemic control. |
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