Family Health Strategy and determinants of directly observed treatment for tuberculosis in Brazil: a cross-sectional study with surveillance system data, 2014-2016

Cola, João Paulo; Prado, Thiago Nascimento do; Sales, Carolina Maia Martins; Maciel, Ethel Leonor Noia

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Brasil

Epidemiologia e Serviços de Saúde

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Original article • Epidemiol. Serv. Saúde 29 (5) • Nov 2020 • https://doi.org/10.1590/S1679-49742020000500010 copy

Family Health Strategy and determinants of directly observed treatment for tuberculosis in Brazil: a cross-sectional study with surveillance system data, 2014-2016^* * Article derived from the Master’s Degree dissertation entitled ‘Social determinants of health and Family Health Strategy coverage in directly observed treatment for tuberculosis: a hierarchical analysis of longitudinal data in Brazil from 2014 to 2016’, defended by João Paulo Cola at the Federal University of Espírito Santo Public Health Postgraduate Program on July 22nd 2019.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To assess the association between tuberculosis determinants and performance of directly observed treatment (DOT) under different levels of Family Health Strategy (FHS) coverage in Brazil.

Methods:

This was a cross-sectional study using data on tuberculosis cases notified between 2014 and 2016 on the Notifiable Health Conditions Information System, as well as data on FHS coverage in the municipality of residence. Logistic regression was used.

Results:

177,626 individuals were included; being an alcohol user (odds ratio (OR) 1.09 - 95% confidence interval % [95%CI] 1.03;1.16), being deprived of liberty (OR=1.21 - 95%CI 1.12;1.32) and positive sputum smear microscopy (OR=1.15 - 95%CI 1.10;1.21) increased the chances of DOT being performed . When stratified by FHS coverage, these associations became weak in the highest stratum of coverage.

Conclusion:

DOT being performed was associated with determinants of tuberculosis. However, association was not confirmed among residents in municipalities with higher FHS coverage.

Keywords:
Tuberculosis; Social Determinants of Health; Directly Observed Therapy; Family Health Strategy; Cross-Sectional Studies

Determinants	With DOT^a	Without DOT^a	p-value^b
Determinants	N (%)	N (%)	p-value^b
Age, in years (n=177,594)^c
<20	3,058 (50.48)	3,000 (49.52)	0.314
20-39	43,124 (50.04)	43,049 (49.96)
40-59	29,806 (49.64)	30,241 (50.36)
≥60	12,580 (49.69)	12,736 (50.31)
Sex (n=177,608)^c
Female	25,882 (47.95)	28,097 (52.05)	<0.001
Male	62,691 (50.71)	60,938 (49.29)
Race/skin color (n=165,046)^c
White	28,474 (50.12)	28,341 (49.88)	<0.001
Black	11,770 (49.67)	11,927 (50.33)
Brown	40,899 (50.06)	40,803 (49.94)
Asian and indigenous	1,833 (64.72)	999 (35.28)
Years of schooling (n=133,839)^c
Illiterate	4,827 (58.83)	3,378 (41.17)	<0.001
1-4	17,773 (53.78)	15,273 (46.22)
5-8	33,409 (50.36)	32,930 (49.64)
>8	10,957 (41.74)	15,292 (58.26)
Geographic region of Brazil (n=177,566)^c
Southeast	42,199 (52.22)	38,607 (47.78)	<0.001
Northeast	20,984 (46.30)	24,336 (53.70)
Midwest	5,235 (60.84)	3,369 (39.16)
South	12,661 (49.63)	12,852 (50.37)
North	7,499 (43.29)	9,824 (56.71)
Zone of residence (n=131,833)^c
Urban	55,692 (47.12)	62,489 (52.88)	<0.001
Rural	7,632 (62.23)	4,633 (37.77)
Peri-urban	630 (45.42)	757 (54.58)
Deprived of liberty (n=131,205)^c
No	56,355 (48.38)	60,138 (51.62)	<0.001
Yes	8,814 (59.91)	5,898 (40.09)
Health worker (n=126,981)^c
No	62,251 (49.67)	63,070 (50.33)	<0.001
Yes	675 (40.66)	985 (59.34)
Street dweller (n=130,658)^c
No	62,418 (49.65)	63,291 (50.35)	0.098
Yes	2,398 (48.45)	2,551 (51.55)

Determinants	With DOT^a	Without DOT^a	p-value^b
Determinants	N (%)	N (%)	p-value^b
HIV/AIDS (n=156,548)^c
No	72,570 (51.93)	67,173 (48.07)	<0.001
Yes	6,603 (39.29)	10,202 (60.71)
Alcohol use (n=166,334)^c
No	66,332 (49.39)	67,977 (50.61)	<0.001
Yes	16,861 (52.65)	15,164 (47.35)
Illicit drug use (n=131,122)^c
No	56,069 (50.09)	55,867 (49.91)	0.005
Yes	9,399(48.99)	9,787 (51.01)
Tobacco smoking (n=131,513)^c
No	51,365 (49.63)	52,128 (50.37)	<0.001
Yes	14,329 (51.14)	13,691 (48.86)
Diabetes (n=165,530)^c
No	76,303 (50.06)	76,110 (49.94)	0.222
Yes	6,494 (49.51)	6,623 (50.49)
Mental disorder (n=165,303)^c
No	80,270 (49.84)	80,795 (50.16)	<0.001
Yes	2,405 (56.75)	1,833 (43.25)
Type of notification (n=177,626)^c
New case	73,404 (50.51)	71,930 (49.49)	<0.001
Relapse	6,767 (50.65)	6,592 (49.35)
Restart after treatment dropout	6,108 (43.55)	7,917 (56.45)
Transfer	2,149 (47.17)	2,407 (52.83)
Not known	158 (44.89)	194 (55.11)
Clinical form (n=177,626)^c
Pulmonary	78,428 (51.22)	74,691 (48.78)	<0.001
Extrapulmonary	8,271 (41.84)	11,496 (58.16)
Extrapulmonary + pulmonary	1,893 (39.94)	2,847 (60.06)
Sputum smear microscopy (n=174,625)^c
Negative	18,064 (47.72)	19,791 (52.28)	<0.001
Positive	52,966 (52.80)	47,341 (47.20)
Not performed	16,446 (45.10)	20,017 (54.90)
Culture (n=175,970)^c
Negative	9,685 (53.88)	8,289 (46.12)	<0.001
Positive	21,466 (54.66)	17,804 (45.34)
In progress	2,056 (44.50)	2,564 (55.50)
Not performed	54,657 (47.90)	59,449 (52.10)
Chest x-ray (n=140,323)^c
Not suggestive of tuberculosis	4,567 (45.92)	5,378 (54.08)	<0.001
Suspected tuberculosis	63,955 (49.05)	66,423 (50.95)

Determinants	OR^b (IC95%^c)	p-value
Level 1
Age, in years		<0.001^e
<20	Reference
20-39	0.91 (0.82;1.01)
40-59	0.85 (0.77;0.95)
≥60	0.78 (0.69;0.87)
Sex		0.064^d
Female	Reference
Male	1.03 (0.99;1.08)
Race/skin color		<0.001^e
White	Reference
Black	0.85 (0.80;0.90)
Brown	0.91 (0.87;0.95)
Asian and indigenous	1.80 (1.54;2.10)
Years of schooling		<0.001^e
No schooling	Reference
1-4	0.79 (0.73;0.86)
5-8	0.58 (0.53;0.63)
>8	0.45 (0.41;0.49)
Level 2
Geographic region of Brazil		<0.001^e
Southeast	Reference
Northeast	0.49 (0.46;0.51)
Midwest	1.11 (1.01;1.21)
South	0.88 (0.83;0.92)
North	0.49 (0.46;0.53)
Zone of residence		<0.001^e
Urban	Reference
Rural	1.65 (1.54;1.78)
Peri-urban	1.00 (0.80;1.24)
Deprived of liberty		<0.001^d
No	Reference
Yes	1.21 (1.12;1.32)
Health worker		0.002^d
No	Reference
Yes	0.77 (0.66;0.91)
Street dweller		0.098^d
No	Reference
Yes	1.10 (0.98;1.23)
Level 3
HIV/AIDS		<0.001^d
No	Reference
Yes	0.69 (0.65;0.73)
Alcohol use		0.001^d
No	Reference
Yes	1.09 (1.03;1.16)
Illicit drug use		0.106^d
No	Reference
Yes	0.94 (0.88;1.01)
Tobacco smoking		0.585^d
No	Reference
Yes	0.98 (0.93;1.03)
Diabetes		0.386^d
No	Reference
Yes	1.03 (0.96;1.10)
Mental disorder		0.007^d
No	Reference
Yes	1.17 (1.04;1.32)
Level 4
Type of notification		<0.001^e
New case	Reference
Relapse	0.88 (0.81;0.95)
Restart after treatment dropout	0.74 (0.68;0.79)
Transfer	0.92 (0.82;1.02)
Not known	0.47 (0.24;0.91)
Clinical form of tuberculosis		<0.001^e
Pulmonary	Reference
Extrapulmonary	0.80 (0.74;0.86)
Extrapulmonary + pulmonary	0.73 (0.65;0.82)
Sputum smear microscopy		<0.001^e
Negative	Reference
Positive	1.15 (1.10;1.21)
Not performed	0.93 (0.88;0.99)
Culture		<0.001^e
Negative	Reference
Positive	0.89 (0.83;0.96)
In progress	0.68 (0.60;0.77)
Not performed	0.68 (0.64;0.73)
Chest x-ray		<0.001^d
Not suggestive of tuberculosis	Reference
Suspected tuberculosis	0.85 (0.78;0.93)

Determinants	Coverage <40% (N=9,167)^a		Coverage from 40 to 70% (N=21,668)^a		Coverage >70% (N=13,658)^a
Determinants	OR^b (IC95%^c)	p-value	OR^b (IC95%^c)	p-value	OR^b (IC95%^c)	p-value
Level 1
Age, in years		0.038^d		<0.001^d		0.466^d
<20	Reference		Reference		Reference
20-39	0.94 (0.72;1.22)		0.93 (0.80;1.07)		0.98 (0.80;1.19)
40-59	0.81 (0.61;1.06)		0.86 (0.75;1.00)		0.96 (0.78;1.17)
≥60	0.82 (0.62;1.10)		0.75 (0.64;0.87)		0.90 (0.73;1.11)
Sex		0.251^e		0.468^e		0.427^e
Female	Reference		Reference		Reference
Male	1.06 (0.95;1.17)		1.02 (0.96;1.08)		1.03 (0.95;1.11)
Race/skin color		<0.001^d		<0.001^d		<0.001^d
White	Reference		Reference		Reference
Black	0.59 (0.50;0.69)		1.04 (0.96;1.13)		0.96 (0.84;1.08)
Brown	0.73 (0.65;0.81)		1.17 (1.10;1.24)		0.84 (0.77;0.91)
Asian and indigenous	1.02 (0.66;1.58)		2.55 (1.97;3.31)		1.29 (1.01;1.64)
Years of schooling		<0.001^d		<0.001^d		<0.001^d
Illiterate	Reference		Reference		Reference
1-4	0.76 (0.60;0.96)		0.98 (0.86;1.12)		0.89 (0.78;1.01)
5-8	0.51 (0.41;0.65)		0.73 (0.64;0.83)		0.83 (0.72;0.94)
>8	0.41 (0.32;0.53)		0.62 (0.54;0.71)		0.60 (0.52;0.69)
Level 2
Geographic region of Brazil		<0.001^d		<0.001^d		<0.001^d
Southeast	Reference		Reference		Reference
Northeast	0.42 (0.34;0.51)		0.27 (0.24;0.29)		0.66 (0.60;0.74)
Midwest	14.74 (12.08;17.99)		0.55 (0.47;0.64)		0.61 (0.52;0.72)
South	4.24 (3.58;5.01)		0.52 (0.48;0.55)		1.30 (1.15;1.47)
North	2.08 (1.77;2.45)		0.28 (0.25;0.32)		0.78 (0.68;0.91)
Zone of residence		<0.001^d		<0.001^d		<0.001^d
Urban	Reference		Reference		Reference
Rural	0.91 (0.72;1.16)		1.67 (1.42;1.97)		1.19 (1.08;1.32)
Peri-urban	6.25 (3.18;12.26)		0.65 (0.46;0.92)		0.69 (0.49;0.98)
Deprived of liberty		<0.001^e		0.154^e		<0.001^e
No	Reference		Reference		Reference
Yes	3.23 (2.58;4.04)		1.09 (0.96;1.23)		1.45 (1.23;1.71)
Health worker		0.186^e		0.003^e		0.005^e
No	Reference		Reference		Reference
Yes	0.70 (0.55;0.88)		0.65 (0.48;0.89)		0.66 (0.50;0.88)
Street dweller		0.033^e		0.119^e		0.862^e
No	Reference		Reference		Reference
Yes	1.41 (1.02;1.94)		1.11 (0.97;1.29)		1.02 (0.76;1.36)
Level 3
HIV/AIDS		0.003^e		<0.001^e		<0.007^e
No	Reference		Reference		Reference
Yes	0.74 (0.61;0.90)		0.69 (0.63;0.75)		0.81 (0.70;0.94)
Alcohol use		0.154^e		0.018^e		0.798^e
No	Reference		Reference		Reference
Yes	1.12 (0.95;1.33)		1.10 (1.01;1.19)		0.98 (0.89;1.09)
Illicit drug use		0.001^e		0.800^e		0.121^e
No	Reference		Reference		Reference
Yes	0.71 (0.57;0.87)		0.98 (0.90;1.07)		1.12 (0.97;1.29)
Tobacco smoking		0.095^e		0.227^e		0.987^e
No	Reference		Reference		Reference
Yes	1.13 (0.97;1.31)		0.95 (0.88;1.02)		1.00 (0.90;1.10)
Diabetes		0.089^e		0.802^e		0.709^e
No	Reference		Reference		Reference
Yes	1.17 (0.97;1.41)		1.01 (0.91;1.12)		1.02 (0.90;1.16)
Mental disorder		0.903^e		0.074^e		0.106^e
No	Reference		Reference		Reference
Yes	1.02 (0.70;1.47)		1.15 (0.98;1.35)		1.22 (0.95;1.56)
Level 4
Type of notification		0.035^d		<0.001^d		0.018^d
New case	Reference		Reference		Reference
Relapse	0.91 (0.73;1.13)		0.86 (0.77;0.96)		0.95 (0.81;1.11)
Restart after treatment dropout	0.83 (0.67;1.04)		0.82 (0.75;0.91)		0.76 (0.65;0.90)
Transfer	0.69 (0.50;0.95)		0.93 (0.78;1.09)		0.96 (0.79;1.16)
Not known	0.14 (0.15;1.28)		0.28 (0.28;1.52)		0.31 (0.50;1.91)
Clinical form of tuberculosis		0.032^d		<0.001^d		0.018^d
Pulmonary	Reference		Reference		Reference
Extrapulmonary	0.76 (0.62;0.94)		0.78 (0.70;0.87)		0.86 (0.75;0.99)
Extrapulmonary + pulmonary	1.14 (0.79;1.64)		0.68 (0.59;0.79)		0.74 (0.58;0.95)
Sputum smear microscopy		<0.001^d		<0.001^d		<0.001^d
Negative	Reference		Reference		Reference
Positive	1.35 (1.16;1.58)		1.20 (1.11;1.29)		1.10 (1.00;1.20)
Not performed	1.13 (0.96;1.33)		1.09 (1.00;1.19)		0.86 (0.77;0.96)
Culture		<0.001^d		<0.001^d		<0.001^d
Negative	Reference		Reference		Reference
Positive	0.93 (0.76;1.13)		0.77 (0.69;0.86)		1.05 (0.90;1.21)
In progress	0.79 (0.54;1.15)		0.65 (0.55;0.77)		0.71 (0.52;0.97)
Not performed	0.62 (0.53;0.74)		0.55 (0.50;0.61)		0.87 (0.77;0.98)
Chest x-ray		0.672^e		0.314^e		0.912^e
Not suggestive of tuberculosis	Reference		Reference		Reference
Suspected tuberculosis	1.05 (0.81;1.38)		0.93 (0.82;1.06)		0.99 (0.85;1.14)

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[1] Correspondence: João Paulo Cola - Universidade Federal do Espírito Santo, Laboratório de Epidemiologia, Av. Marechal Campos, No. 1468, Maruípe, Vitória, ES, Brazil. Postcode: 29040-090. E-mail: joaopaulocola@gmail.com