Social and Economic Factors Leading to Delayed Diagnosis of MDR-TB and Affecting Success of Ambulatory Treatment in Rural Haiti: A Three-Part Mixed Methods Study.

Abstract

Living in conditions of rampant poverty and deep social inequality, patients with drugs-resistant TB in remote areas of Haiti face important barriers that delay appropriate treatment initiation and impact their ability to complete treatment. As Haiti aims to decentralize MDR-TB treatment, a good understanding of how these barriers can inform an improved treatment approach. I conducted a mixed method study at two MDR-TB facilities in rural Haiti to document treatment response at discharge from hospital and identify factors that impact MDR-TB treatment initiation and continuation. We enrolled 17 MDR-TB, patients, 16 family members. I conducted: • A first qualitative interview with patients at discharge (N=17) to assess factors creating delay before appropriate treatment initiation. • A longitudinal (during first four months after discharge) quantitative data collection of bio-medical data from patients’ charts; scores from a newly developed composite measure of clinical response (0-10, 10 indicating the most compromised response) that uses BMI, hemoglobin, chest X-ray, side effects, microbiology, activities of daily life, food insecurity, and depression. • A second interview with the same patients and family caregivers in patients’ homes to identify obstacles to successful treatment response. The mean monthly clinical response score was 3 (range:1-8). Patients with worse response had: low BMI, low hemoglobin, compromised activities of daily life, more treatment sides effects, depression, and food insecurity. The qualitative analysis suggests that factors contributing to delayed treatment initiation are present at treatment initiation as well as at discharge and may compromise response. These include financial (lost wages, costly transportation) and logistical barriers to reaching highly centralized treatment facilities. The results highlight the socio-economic, geographical and structural barriers that patients with drugs-resistant TB in rural Haiti face to find and successfully complete lifesaving treatment. Integrating qualitative and quantitative data reveal that patients with poorer response also had limited social support and difficult living conditions. Properly implemented decentralized care could help overcome geographical barriers. Strong nutritional, social and financial support are essential to support appropriate treatment for the disease.