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Text for Figures and Slides in TB Behavioral and Social Science Research Forum Proceedings

PSYCHOSOCIAL, SOCIAL STRUCTURAL, AND ENVIRONMENTAL DETERMINANTS OF TUBERCULOSIS CONTROL

Donald E. Morisky, Sc.D., M.S.P.H., Sc.M.
Professor, Department of Community Health Sciences
UCLA School of Public Health

Slide #1: Psychosocial, Social Structural, and Environmental Determinants of TB Control

Donald E. Morisky, Sc.D., M.S.P.H., Sc.M.
Professor and Program Director for Social and Behavioral Determinants of AIDS and Tuberculosis Training
Department of Community Health Sciences UCLA School of Public Health

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Slide #2: Issues of Noncompliance

  • Typically associated with homelessness, drug or alcohol abuse and/or minimal educational achievement
  • Multiple drug resistant TB (MDR-TB)
  • Cited as the major cause of the increase in incidence rates of TB
  • Directly Observed Treatment -- Short Course (DOTS)
    • Reason for Dots.

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Slide #3: Methods

R (Site 1)

E1 - Educational counseling;
E2 - Incentives/rewards;
E3 - Combination of E1 and E2;

Site 2

C - Usual care

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Slide #4: Methods

  • A total of 241 patients were randomly assigned to one of three intervention groups or the control.
  • The patients were followed throughout their treatment program. Cognitive and behavioral outcome markers were used to assess the effectiveness of the educational intervention.

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Slide #5: Three Categories of Factors Contributing to Compliance to an Anti-Tuberculosis Regimen

Compliance to an anti-tuberculosis regimen involves:

Cognitive Factors

  • Knowledge
  • Beliefs
  • Values
  • Attitudes

Environmental Factors

  • Availability/Accessibility to Care
  • Travel to Health Facility
  • Walking Time
  • Health Related Skills
  • Complexity of Medical Regimen

Reinforcing Factors

  • Family
  • Peers
  • Employer
  • Health Care Provider
  • Health Educator

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Slide #6: Demographic (For all eligible participants interviewed (N=241)

Survey Item Distribution
Male
63%
Hispanic Ethnicity
62%
Black Ethnicity
25%
Spanish-speaking
60%
Unemployed
63%
Education < High School graduate
55%
Annual Family Income < $10,000
42%

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Slide #7: Length of Care for Participants in Program (average weeks)

Intervention Groups (n=60)

  • Education = 32.27 wks
  • Incentives = 37.13 wks
  • Combined = 31.96 wks

Control Group (n=61)

  • 39.66 wks

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Slide #8: Intervention Effects Between Baseline Interview and Exit Interview

Knowledge Scale:

Intervention Group
Percentage Difference
(Post-test vs Pre-test)
p - value
(Paired t-test)
C - Control
+ 1.5% .860
E1 - Education
+ 31.7% .009**
E2 - Incentives
+ 20.5% .059
E3 - Combined + 26.7% .046*

* p < 0.05
** p < 0.01


Medication Compliance:

Intervention Group
Percentage Difference
(Post-test vs Pre-test)
p - value
(Paired t-test)
C - Control
+ 9.7% .47
E1 - Education
+ 26.5% .006**
E2 - Incentives
+ 14.1% .067
E3 - Combined + 16.7% .061


* p < 0.05
** p < 0.01

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Slide #9: Cost per Completed Case

Intervention Groups:

  • Education (n=61) = $1,647.50
  • Incentives (n=60) = $1,770.70
  • Combined (n=60) = $2,070.80

Control Group (n=60)

  • $2,680.10

ANOVA: p=0.04

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Slide #10: Appointment-Keeping Behavior for Participants

Control = 84.30%
All interventions = 89.70%

p=0.04

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Slide #11: Average Weeks of Treatment Until Completion of Care

Control = 38.4 wks
All interventions = 32.9 wks

p=0.04

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Slide #12: Factors to consider for drop out rates

  • Ethnic Background
  • Sex
  • Unemployment
  • Homeless
  • Drug Use
  • HIV
  • Primary Language
  • Marital Status

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Slide #13: Adolescent TB Program

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Slide #14: Why Focus on Adolescents ?

  • Incidence of TB increases at adolescence1
  • Adolescents more susceptible to active TB2
  • Time interval between infection and development of active disease is shorter3
  • Adherence among adolescents
  1. Starke, JR. Infectious diseases of health significance among children and adolescents in Texas. Texas Med 90:35-45, 1994.
  2. Wilcox WD, Laufer S. Tuberculosis in Adolescents. A Case Commentary.  Clinical Pediatrics,1994; 33:258-262. Smith MHD. Tuberculosis in adolescents. Clinical Pediatrics, 1967; 6:9-15.
  3. McCue M, Afifi LA.  Using peer helpers for tuberculosis prevention. J Am College Health 1996 Jan, 44(4):173-6.

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Slide #15: Background of TB Study

  • Rationale: Preventive TB treatment study
  • Sites:Long Beach and Inglewood Public Health Clinics
  • Participants: Ethnically diverse adolescents aged 11-19 years old (n=794)
  • Randomized in 4 treatment groups (peer counseling only, incentive only, combination of peer counseling and incentive, usual care)
  • Procedure-Face to face interviews, baseline and 6 month follow-up
  • The present report only includes foreign-born adolescents (80% of study population)

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Slide #16: Independent Variables

  • Socio-demographic variables
  • Clinic related variables (e.g. waiting time)
  • High-risk behaviors (alcohol, drug use,  gang membership, incarceration)
  • Psycho-social variables (self-esteem,  mastery, self-efficacy)

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Slide #17: Model of Study Group Design – Intervention Experimental Design

Recruitment Baseline Interview and Randomization (n=880)

¯

-Peer Counseling (n=220)
-Contingency Contracting (n=220)
-Combined Peer and Parent Intervention (n=220)
-Usual Care (n=220)

¯

Follow to treatment completion or drop-out

¯

Final interview

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Slide #18: Quasi-Experimental/Control Design Study for Adolescent Participants at Baseline Surveys (Recruitment: July 1996 – October 1997)

Recruitment: Baseline Interview and Randomization (Baseline N=390)
(Los Angeles: n=191; Long Beach: n=199)

¯

E1-Peer Counseling (Baseline n=94)
E2-Contingency Contracting (Baseline n=100)
E3-Peer Counseling and Contingency Contracting (Baseline n=96)
C-Standard Care (Control); (Baseline n=100)

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Slide #19: Theoretical Conceptual Framework
-Knowledge
-Attitudes
-Beliefs
-Self Efficacy
-Behavioral Intention
-Subjective Norms

¯

Increased Compliance

¯

Tuberculosis Prevention

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Slide #20: Characteristics of Foreign-born Adolescents

  • 20% failed to complete treatment
  • 45% live with both parents
  • 78% rate their health as good
  • 2% are gang members
  • 23% are sexually active
  • 8% report a history of incarceration

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Slide #21: Factors Associated with Completion of Care

  • Age (OR=0.85; 95% CI: .76-.85)
  • Asian ethnicity (OR=3.37; 95% CI .99-.11.44)
  • Living with both parents (OR=2.13; 95% CI: 1.37-3.31)
  • Speaking only English with parents (OR=0.34; 95% CI: .16-.74)
  • Sexually active (OR=0.43; 95% CI: .28-.68)
  • Gang member (OR=0.26; 95% CI: .07-.87)
  • Incarceration (OR=0.50; 95% CI: .26-.94)
  • Medication taking behavior (OR=1.25; 95% CI: 1.14-1.37)

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Slide #22: Independent Predictors of Completion of Care

  • Medication taking behavior (OR=1.28; 95% CI:1.16-1.41)
  • Living with both parents (OR=1.87; 95% CI:1.08-3.25)
  • Sexual intercourse (OR=0.54; 95% CI-.31-.94)
  • Speaking mostly or only English with parents (OR=.34; 95% CI .12-.91)

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Slide #23: Recommendations

  • Need to collect more specific information
  • Encourage clinic procedures that increase compliance
  • Recruit supportive family members /friends to facilitate treatment
  • Future research should focus on foreign-born adolescent populations in various regions of the US

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Slide #24:

Individual Determinants of Compliance
  • Understanding the medical regimen
  • Belief in the benefits of treatment
  • Positive attitudes regarding treatment
  • High levels of self esteem and self efficacy

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Slide #25:

Environmental Determinants of Compliance
  • Family member reinforcement in the home
  • Good patient/provider communication
  • Systematic approaches for patient monitoring, follow up and reinforcement
  • Convenience of picking up medication from the clinic
  • Use of pill containers and cueing behaviors

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Slide #26:

Individual/Environmental Determinants of Completion of Care
  • Regular appointment-keeping behavior
  • High levels of adherence
  • Community health workers
  • Reinforcement of positive behaviors by health care staff
  • Peer counselors to clarify health concerns

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Released October 2008
Centers for Disease Control and Prevention
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