Psycological Distress Among MDR TB Patients in India.pdf

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and long-term socio-economic and psychological effects.

To study the prevalence of psychological distress among the MDR TB patients in India. The universe of the study are the patients those who are affected by MDR TB and undergoing treatment

beyond six months and those who are above the age of 18 years. The study was conducted

among three States of India, Bihar, Andhra Pradesh and Delhi. A

total of 610 patients were interviewed. Descriptive

research design was adopted for the study.

A structured inter view schedule was instrumented along with the General Health Question naire (GHQ 12) adopted with Likert scale to collect data

on general health to assess the evidence of

psychological distress among the MDR TB

patients. Results: Among the total respondents 19.3 percent

of them had severe problem and psychological distress and 7.4 percent had

evidence of distress. Majority of the respondents those who had severe problems and

Objective:

Methods:

Indian Streams Research Journal Impact Factor : 3.1560(UIF) ISSN 2230-7850 Volume - 5 | Issue - 10 | Nov - 2015

PREVALENCE OF PSYCHOLOGICAL DISTRESS AMONG MULTI DRUG RESISTANT TB PATIENTS IN INDIA

1 2Lawrence Camillus Rajkumar and K.Sathyamurthi

1Research Scholar, Karpagam University, Coimbatore, Tamilnadu, India.2Research Guide &Supervisor, Madras School of Social Work, Chennai.

ABSTRACT: uberculosis (TB) remains as a major public health problem Tand one of the world’s

deadliest communicable diseases. Globally there were an estimated 9 million new cases of TB in 2013.There were an estimated 1.5 million deaths and in the year 2012 an estimated 170,000 deaths from MDR TB, and 450,000 new cases of MDR TB. Though India is the second-most populous country in the world one fourth of the global incident TB cases occur in India annually. India accounts for 24 percent of world TB cases. In 2013 alone, around 4, 80,000 p e o p l e w e r e estimated to have developed MDR-TB. More than half of these cases were in India, China and the Russian Federation. It is estimated that around 61,000 people in India have developed MDR TB during the year 2013. Patients with MDR-TB also require longer courses of more cost ly treatment and experience higher mortality than those with drug susceptible TB. Furthermore, it can take more than 2 years to treat MDR-TB, resulting in social isolation, loss of employment

Available online at www.lsrj.in

Lawrence Camillus Rajkumar

1


psychological distress were young (9.2%), married (13.6%), from nuclear family (10%), had three and more children in their family (7.5%), were unemployed (12%), did not have any income (9.7%), had taken previous TB treatment (18.9%), were not isolated by their family (14.9%) and provided separate utensils to take food (17.5%) were those who had severe problems and psychological distress. Conclusion: Severe problems and psychological distress were evident amongst young, females and married MDR TB patients. The study also revealed a clear linkage between MDR TB patient’s psychological distresses with illiteracy and low socio economic status. Psychological distress was strongly co-associated with the MDR TB patients those who had taken previous treatment for TB. Isolation of MDR TB patients by the family members play a major role towards contributing to psychological distress among MDR TB patients.

Psychological Distress, Evidence of Distress, MDR TB, Drug Resistant TB, India.

Tuberculosis (TB) remains as a major public health problem and one of the world’s deadliest communicable diseases. TB is an infectious disease caused by Mycobacterium tuberculosis and is commonly spread through droplet infection. TB is one of the most ancient diseases of mankind, with molecular evidence going back to over 17,000 years. Despite of newer modalities for diagnosis and treatment, unfortunately, people are still suffering, and TB is among the top 10 killer infectious diseases in the world, second only to HIV. TB is a worldwide pandemic (6). TB is a devastating disease due to its rapid transmission and high rate of mortality causing around 1.8 million deaths annually. Majority of cases are found in low or low-middle income countries and studies in both high-income and low-income countries demonstrate significantly higher rates of TB in their poorer populations (12).

According to WHO report 2014, (7) in the year 2013, the largest number of new TB cases occurred in the South-East Asia and Western Pacific Regions, accounting for 56 percent of new cases globally. There were an estimated 9 million new cases of TB in 2013. India accounts for 24 percent of world TB cases. There were an estimated 1.5 million deaths and in the year 2012 an estimated 170,000 deaths from MDR TB, and 4,80,000 new people have developed MDR TB. More than half of these cases were in India, China and the Russian Federation. It is estimated that around 61,000 people in India have developed MDR TB during the year 2013. India is the country with the highest burden of TB, WHO statistics for 2013 gives an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million. The estimated TB prevalence figure for 2013 is given as 2.6 million. It is estimated that about 40 percent of the Indian population is infected with TB bacteria, the vast majority of whom have latent rather than active TB. Though India is the second-most populous country in the world one fourth of the global incident TB cases occur in India annually.

Drug resistance in TB may be broadly classified as primary or acquired. Drug resistance in mycobacteria is defined as a decrease in sensitivity to a sufficient degree to be reasonably certain that the strain concerned is different from a sample of wild strains of human type that have never come in contact with the drugs (11). Multi drug resistant tuberculosis (MDR-TB) is a contagious disease, which spreads through droplet nuclei. Multi drug resistant tuberculosis is a type of TB that often develops in patients who do not adhere to or complete the proper treatment for TB. Most of the strains of Mycobacterium Tuberculosis are sensitive to first line anti-TB drugs. Multi Drug Resistant (MDR) TB is caused by strains resistant to Rifampicin & Isoniazid, two key first line anti-TB drugs.

Treating MDR-TB is more complicated than treating drug-susceptible TB, as second-line TB drugs are more difficult to acquire, often require intravenous administration and are more toxic and

KEY WORDS:

I)INTRODUCTION:

Available online at www.lsrj.in 2

less effective than first-line drugs (10). Patients with MDR-TB also require longer courses of more costly treatment and experience higher mortality than those with drug susceptible TB (16). Furthermore, it can take more than 2 years to treat MDR-TB, resulting in social isolation, loss of employment and long-term socio-economic and psychological effects, (2).

The methodological aspects of the research study includes Aim, Objectives, field of study, Research Design, Sampling Design, Sources of Data, Tools for Data Collection and Data Analysis plan which are discussed in this area.

To study the prevalence of psychological distress among the MDR TB patients in India.

The universe of the study are the patients those who are affected by MDR TB and undergoing treatment beyond six months and those who are above the age of 18 years. The study was conducted among three States of India, Bihar, Andhra Pradesh and Delhi. There are 36 districts in Bihar, 13 districts in Andhra Pradesh (Divided A.P from Telengana) and 9 Districts in Delhi. All the patients registered under the Government RNTCP programme in all the three States and as of March 2015, those who have completed 6 months of their treatment form the sample of this study.

The study was conducted in 3 States of India, Bihar, Andhra Pradesh and Delhi. Twenty three districts were selected for the study, 15 districts in Bihar 6 districts in Andhra Pradesh and two districts in Delhi. Proportionate stratified random sampling method was adopted for this study. A total of 610 patients (272 from Bihar, 295 from Andhra Pradesh and 43 from New Delhi) were interviewed.

The researcher adopted quantitative research method for this study a general interview schedule incorporating, Demographic & Personal profile, Socioeconomic condition, TB treatment profile, Current MDR TB treatment profile, Family support profile and Institutional support profile. The General Health Questionnaire (GHQ - 12) along with Likert scale was used for the study.

In this research the researcher describes the characteristic of persons affected by MDR TB and their general health status to study the psychological distress. Hence the researcher adopted the descriptive research design to study the psychological distress of MDR TB patients. A structured interview schedule was instrumented to collect the data along with the General Health Questionnaire (GHQ 12) comprising 12 questions, and adopted with Likert scale, which is self administered screening questionnaire, designed for use in consulting settings aimed at detecting individuals with a diagnosable psychiatric disorder. This tool was used by the researcher to collect the data on general health to assess the evidence of psychological distress among the MDR TB patients. Data were entered and analyzed using SPSS version 16.0.

The evidence of Psychological distress was studied among 610 MDR TB patients, it was found that there were 19.3 percent of the respondents had severe problem and psychological distress, 7.4

II) METHODOLOGY

a)Objective:

b) Study Population:

c) Sampling Frame and Design:

d)Research Design:

III)RESULTS



percent had evidence of distress and remaining (73.3%) respondents were normal without any distress. Among the total respondents (19.3%) those who had severe problem and psychological distress majority (17.9%) of them were from Bihar.

Majority (9.2%) of the respondents those who suffered severe problems and psychological distress were in the age group of 18 to 30 years. Females were high (21.9%), when compared to male (18.2%) respondents those who suffered severe problems and psychological distress. Majority (16.6%) of them those who had severe problems and psychological distress belonged from Hindu religion. Among the respondents those who were affected were mostly (6.2%) illiterates. Majority (13.6%) of them those who were married had severe problems and psychological distress. It was evident to note that majority (10%) of the respondents those who had problems and psychological distress belonged from nuclear family. The respondents those who had three and more children in their family were the majority (7.5%) those who had psychological distress. The study found that psychological distress was high (12%) among the unemployed and secondly majority (9.7%) who did not have any earning were the most affected.

The study also revealed that majority (18.9%) of respondents those who had taken previous treatment for TB had severe problems and psychological distress. The respondents those who shared that they were not isolated by their family members were the majority (14.9%) those who had severe problems and psychological distress. The respondents family those who provided separate glass and plate (utensils) by their family members during the MDR TB illness are the majority (17.5%) who had severe problems and psychological distress.

* In table 1, the State wise distribution of respondents and the evidence of Psychological distress are presented.

*In table 2, the level of distress among the Male and Female respondents are compared.

Table 1. State wise MDT TB patient and Psychological Distress

Table 2. Gender and Psychological Distress


S.No State

General Health Status

Total Normal Evidence of

Distress

Severe problems and psychological

distress 1 Bihar 139 (51.1)

(22.8) 24 (8.8)

(3.9) 109 (40.1)

(17.9) 272

(44.6) 2 Andhra

Pradesh 275 (93.2)

(45.1) 16 (5.4)

(2.6) 4 (1.4)

(.7) 295

(48.4) 3 Delhi 33 (76.7)

(5.4) 5 (11.6)

(.8) 5 (11.6)

(.8) 43

(7.0) Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)

S.No Gender of the

Patient

Level of Distress

Total Normal

Evidence of Distress


distress

1 Male 316 (74.7)

(51.8) 30 (7.1)

(4.9) 77 (18.2)

(12.6) 423

(69.3)

2 Female 131 (70.1)

(21.5) 15 (8.0)

(2.5) 41 (21.9)

(6.7) 187

(30.7)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)


Table 3. Religion and Level of Psychological Distress

Table 4. Educational Qualification and Psychological Distress

*In table 3, The respondents religion and level of distress is compared.

* In table 4, the relationship between educational qualification and evidence of distress level among the MDR TB patients is revealed.


S. No Religion

Level of Distress

Total Normal



distress

1 Hindu 330 (70.2)

(54.1) 39 (8.3)

(6.4) 101 (21.5)

(16.6) 470

(77.0)

2 Muslim 87 (82.9)

(14.3) 4 (3.8)

(.7) 14 (13.3)

(2.3) 105

(17.2)

3 Christian 29 (87.9)

(4.8) 2 (6.1)

(.3) 2 (6.1)

(.3) 33

(5.4)

4 Others 1 (50.0)

(.2) 0 (.0)

(.0) 1 (50.0)

(.2) 2

(.4)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)

S.No Educational Qualification

Level of Distress

Total Normal


Severe problems and

psychological distress

1 Illiterate 141 (73.4)

(23.1) 13 (6.8)

(2.1) 38 (19.8)

(6.2) 192

(31.5)

2 Primary 99 (83.2)

(16.2) 7 (5.9)

(1.1) 13 (10.9)

(2.1) 119

(19.5)

3 High School 109 (69.0)

(17.9) 16 (10.1)

(2.6) 33 (20.9)

(5.4) 158

(25.9)

4 Higher Secondary 36 (60.0)

(5.9) 5 (8.3)

(.8) 19 (31.7)

(3.1) 60

(9.8)

5 Under Graduate 53 (76.8)

(8.7) 3 (4.3)

(.5) 13 (18.8)

(2.1) 69

(11.3)

6 Post Graduate 8 (72.7)

(1.3) 1(9.1)

(.2) 2 (18.2)

(.3) 11

(1.8)

7 Others 1 (100.0)

(.2) 0 (.0)

(.0) 0 (.0)

(.0) 1

(.2)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)


Table 5. Employment and Psychological Distress

Table 6. Previous Treatment for TB and Psychological Distress

Table 7. Separate Utensils for Patient and Psychological Distress

IV) DISCUSSION

* In table 5, the relationship between the employment and level of distress among the MDR TB patients are presented.

* In table 6, the relationship between patients those who have taken treatment for TB before MDR TB course of treatment and the patient distress level is compared.

* In table 7, the relationship between the MDR TB patients those who were being provided utensils for taking daily food during TB illness and the evidence of psychological distress is revealed.

The study indicated that psychological distress among female are more when compared to male


S.No Patient

Employment

Level of Distress

Total Normal



distress

1 Employed 136 (88.9)

(22.3) 6 (3.9)

(1.0) 11 (7.2)

(1.8) 153

(25.1)

2 Un Employed 211 (67.4)

(34.6) 29 (9.3)

(4.8) 73 (23.3)

(12.0) 313

(51.3)

3 Student 36 (70.6)

(5.9) 2 (3.9)

(.3) 13 (25.5)

(2.1) 51

(8.4)

4 House Wife 64 (68.8)

(10.5) 8 (8.6)

(1.3) 21 (22.6)

(3.4) 93

(15.2)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)

S.No

Patient Taken Previous

Treatment for TB

Level of Distress

Total Normal



distress

1 Yes 429 (73.0)

(70.3) 44 (7.5)

(7.2) 115 (19.6)

(18.9) 588

(96.4)

2 No 18 (81.8)

(3.0) 1 (4.5)

(.2) 3 (13.6)

(.5) 22

(3.6)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)

S.No

Separate Utensils for

taking food at home

Level of Distress

Total Normal



distress

1 Yes 325 (69.9)

(53.3) 33 (7.1)

(5.4) 107 (23.0)

(17.5) 465

(76.2)

2 No 122 (84.1)

(20.0) 12 (8.3)

(2.0) 11 (7.6)

(1.8) 145

(23.8)

Total 447 (73.3) 45 (7.4) 118 (19.3) 610 (100.0)


MDR TB patients, which can be attributed to increased exposure to infections among males and decreased health seeking behaviors of Females. These findings are supported by study by A Faustini et. al, (2006) [4] which showed male dominance over female when tuberculosis is concerned.

Majority of the respondents those who suffered psychological distress were in the age group of 18 to 30 years and majority (16.6%) belonged to Hindu religion, which is similar to the finding of Meera Dhuria et. al, (2008) [14] on the study were majority (70%) of the patients belonged to 20-39 years age group were Hindus and married. Similarly Neha Deo et. al, (2012) [15] showed that Younger age groups (<40 years) were more likely to develop MDR-TB/TB and side effects than older.

Among the respondents those had severe problems and psychological distress were high (6.2%) among the illiterates, which is supported by the study conducted by Gajanan S. Gaude et. al, (2014) [8] which proved low Education status (P = 0.01) has significant association with Tuberculosis. The study found that psychological distress was high among the unemployed and those who had large family with three or more children and did not have any earning, which is supported by study of Gajanan S. Gaude et. al, (2014) [8] which showed significant association of low socio-economic status and Tuberculosis.

Majority (13.6%) of them those who were married had problems and psychological distress. This is lines with the study conducted in Pakistan by Waqas et, al, (2012) [13] where the high incidence of T.B in the married alarm the concerns about the spreading consequences in the population. Majority (18.9%) of respondents those who had taken previous treatment for TB had severe problems and psychological distress, this is in coherence with the study conducted by Theron et al (2015) [18] where previous TB are associated with increased levels of psychological distress amongst patients with symptoms of TB, however, TB status is not.

The majority (14.9%) of the respondents those who shared that they were not isolated by their family members were those who had severe problems and psychological distress. The respondents family those who were provided separate glass and plate (utensils) by their family members during the MDR TB illness are the majority (17.5%) who had severe problems and psychological distress, which is similar to the study of Sharma et, al (2013) [17] where MDR TB and PTB patients, social functioning was affected through isolation; variable social support by family and friends, and inability to continue with social and leisure activities.

Overall, in this study it was found that severe problems and psychological distress to be frequent amongst young MDR TB patients. The psychological distress was high among female respondents and among the married MDR TB patients. The study also revealed a clear linkage between MDR TB patient’s psychological distresses with illiteracy and low socio economic status. Psychological distress was strongly co-associated with the MDR TB patients those who had taken previous treatment for TB. Isolation of MDR TB patients by the family members play a major role towards contributing to psychological distress among MDR TB patients.

This study has shown that the psychological distress of MDR TB patients vary according to the age, gender, culture, religious practice, social status, personal traits, demographic profile and socio economic conditions. The physical, psychological, social and environmental aspects linked with poverty and illiteracy is the determinant factor for ascertaining the psychological distress. Therefore this study shall be useful for future social workers and other public health professionals to take up further research to improve the general health status of MDR TB patients.

V) CONCLUSION



VI) ACKNOWLEDGEMENTS

VII) CONFLICT OF INTEREST

VIII) REFERENCES

The authors are grateful to the patients for their willingness to participate in this study. We gratefully acknowledge Damien Foundation India Trust’s Secretary, Medical Officers and Field TB Coordinators of Bihar, Andhra Pradesh & Delhi for their support and cooperation for this study.

None to declare.

1)Ananthakrishnan R, Muniyandi M, Jeyaraj A, Palani G, Sathiyasekaran B. Expenditure Pattern for TB Treatment among Patients Registered in an Urban Government DOTS Program in Chennai City, South India. Tuberculosis Research and Treatment 2012; 2012.2)Abegunde DO, Stanciole AE. The economic impact of chronic diseases: how do households respond to shocks? Evidence from Russia. Social Sci Med 2008;66(11):2296–307.3)Aggarwal, A.N. (2010) Health Related Quality of Life: A Neglected Aspect of Pulmonary Tuberculosis. Lung India, 27, 1-3. http://dx.doi.org/10.4103/0970-2113.59259.4)A Faustini, A J Hall, C A Perucci. Risk factors for multidrug resistant tuberculosis in Europe: a systematic review Thorax 2006; 61: 158–163. 5)Chamla, D. (2004) The Assessment of Patients’ Health-Related Quality of Life during Tuberculosis Treatment in Wuhan, China. International Journal of Tuberculosis and Lung Disease, 8, 1100-1106.6)Gadhave NA, Lade KS, Singh MC, Sawant SD. Tuberculosis: A dreaded or curable disease –A Review. J Pharma Re 2011;4:2107–19.7)Global Tuberculosis Control 2014, WHO, Geneva Report.8)Gajanan S. Gaude, Jyothi Hattiholli, Praveen Kumar. Risk factors and drug-resistance patterns among pulmonary tuberculosis patients in northern Karnataka region, India Nigerian Medical Journal, 2014 august; 55 (4): 327–332.9)Hansel, N.N., Wu, A.W., Chang, B. and Diette, G.B. (2004) Quality of Life in Tuberculosis: Patient and Provider Perspectives. Quality of Life Research, 13, 639-652. 10)Iseman M D. Treatment of multidrug-resistant tuberculosis. N Engl J Med 1993; 329: 7847–7891.11)Mitchison, DA. Drug resistance in mycobacteria. Br Med Bull 1984; 40: 84-90.12)Malmborg R, Mann G, Squire SB. A systematic assessment of the concept and practice of public-private mix for tuberculosis care and control. Int J Equity Health 2011;10(1):49.13)Masood Sarwar Awan, Muhammad Waqas and Muhammad Amir Aslam. Factors Influencing Quality of Life in Patients with Active Tuberculosis in Pakistan, World Applied Sciences Journal 18 (3): 328-331, 2012.14) Meera Dhuria, Sharma N, Ingle G K. Impact of tuberculosis on the quality of life. Indian J Community Med 2008;33:58-915)Neha deo et al. Risk Factors of Multi-drug Resistant TB: a Case TB Patients Study at Selected DOTS-plus Clinics in Nepal 2011 Health Research and Social Development Forum (HERD) Kathmandu, Nepal. January 2012.16)Ormerod L P. Role of surgery in pulmonary multidrug-resistant tuberculosis. Thorax 2007; 62: 377.17)Sharma R, Yadav R, Sharma M, Saini V, Koushal V, (2013). Quality of life of multi drug resistant tuberculosis patients: a study of north India, Acta Med Iran. 2014;52(6):448-53.18)Theron et al, (2015). BMC Infectious Diseases (2015) 15:253.



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