RESEARCH ARTICLE
Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen Ammar Ali Saleh Jaber*, Amer Hayat Khan, Syed Azhar Syed Sulaiman, Nafees Ahmad, Mohamed Saif Anaam Department of Clinical Pharmacy, School of Pharmaceutical Sciences, USM, Penang, Malaysia * [email protected]
Abstract a11111
Background The health-related quality of life (HRQoL) of Tuberculosis (TB) patients is important because it directly influences the outcome of TB patients in several aspects. The current study aims to evaluate and to find the factors influencing the HRQoL of TB patients in two major TB-prevalent cities (Taiz and Alhodidah) in Yemen.
OPEN ACCESS Citation: Jaber AAS, Khan AH, Syed Sulaiman SA, Ahmad N, Anaam MS (2016) Evaluation of HealthRelated Quality of Life among Tuberculosis Patients in Two Cities in Yemen. PLoS ONE 11(6): e0156258. doi:10.1371/journal.pone.0156258 Editor: Seyed Ehtesham Hasnain, Indian Institute of Technology Delhi, INDIA Received: February 21, 2016 Accepted: May 11, 2016
Methods A prospective study was conducted, and all TB patients meeting the HRQoL criteria were asked to complete the HRQoL SF-36 survey. The records of TB patients were examined for disease confirmation, and a follow-up was consequently performed for patients during treatment between March 2013 and February 2014 in Taiz and Alhodidah Cities. HRQol scores were calculated by using QM scoring software version 4.5, in which the physical component score (PCS) and mental component score (MCS) were obtained. The scores obtained between 47–53 normal based score (NBS) were considered equivalent to the US normal score. Low scores indicate the poor health situation of TB patients
Published: June 3, 2016 Copyright: © 2016 Jaber et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: The authors have no support or funding to report. Competing Interests: The authors have declared that no competing interests exist.
Results A total of 243 TB patients enrolled in the study at the beginning of the treatment. A total of 235 and 197 TB patients completed the questionnaire at the end of the intensive phase (I. P.) and continuation phase (C.P.), respectively. The final dropout rate was 16.2%. The mean PCS and MCS scores at the beginning of treatment were low, thus showing the poor health situation of TB patients. The mean PCS scores at the beginning of treatment, end of I.P., and end of treatment were (36.1), (44.9), and (48), respectively. Moreover, the mean MCS score at the beginning of treatment, end of I.P., and end of treatment were (35.1), (42.2), and (44.3), respectively. The result shows that significant increases are observed at the end of I.P. for PCS and MCS because of the treatment and slight changes at the end of C.P. Despite this finding, the MCS score remains below the normal range (47), thus
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
indicating a significant risk of depression among TB patients. Furthermore, general linear repeated measure ANOVA was performed for selected variables, to examine the changes of PCS and MCS over time. It was found that Alhodiah city, chewing khat habit, stigmatization, and duration of treatment more than six months were greatly associated with low mean MCS score of TB patient, indicating great risk of depression which may result in poor treatment outcome.
Conclusion TB patients in Yemen were found to have poor QoL, with a significant likelihood of depression. Highly risk depression was found among TB patients in Alhodiah city, khat chewers, stigmatization and having a duration of treatment more than 6 months. Therefore, additional efforts should be made to improve their QoL because it may affect the final clinical outcome of patients.
Introduction SF-36V2 health-related quality of life (HRQoL) is a generic self-reported questionnaire that is used to determine the quality of life (QoL) of the general population or individual patients [1]. Moreover, it is used to measure the influence and effects of the disease on patient functions and activities [2]. HRQoL acts as a predictor of patient therapy [3] by giving the health worker the characteristic changes of morbidity at a particular time and helping predict the factors that improve patient satisfaction [4] [5]. Several studies were conducted in different regions and countries to assess and evaluate the effect of tuberculosis (TB) on patients’ QoL [6], [7], [8],[9], [10]. Only a few studies have investigated TB at various treatment stages [11], [12], [9]. HRQoL evaluation is important because it predicts the change of health conditions of subjects at various levels of treatment and eventually affect the treatment outcome of TB patients [3], [4]. TB is considered a major disease, which impairs the daily life activities of the patient. The effect of TB on a patient’s health is considered essential [13] because, it can result to changes in the physical and mental states of the patient, and can consequently affect the treatment outcome [14]. Moreover, even less attention is given to QoL in developing countries as an influential factor, especially in TB disease [15]. WHO recognizes Yemen as an intermediate TB-burdened country [16]. TB in Yemen is considered one of the main health problems and ranks fourth in the priority list of public health issues [17]. In Yemen, the people’s standard QoL is considered low because of poverty, low life standard, and weak governmental health services [18], [19]. However, no study has performed HRQol for TB patients by using SF36 in the two major TB-prevalent cities in Yemen. This study aims to evaluate the HRQoL of TB patients in the two major TB-prevalent cities in Yemen for one year and to find the factors affecting the quality of life of TB patient during the treatment period.
Study Population and Methods This prospective study was conducted at the multicenter of the two major TB-prevalent cities in Yemen (Taiz and Alhodidah) under the National TB Control Program. Taiz City is located approximately 256 km south of Sana’a. Taiz holds the first rank regarding the number of
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
population, with a population representing 12.16% of the total population of Yemen. AlHodeida City is located in the Red Sea Coast at a distance of 226 km from Sana’a; this city ranks second in terms of the number of population, with a population representing nearly 11% of the total population of the republic [17]. All the patients registered between March 2013 and February 2014, met the HRQoL criteria (18 years old and literate) [20], and confirmed their TB diagnosis upon enrollment in the study. Patients who defaulted, died, transferred out, and refused to participate were excluded from the study (Fig 1). In Yemen, all TB patients who underwent diagnosed either in the private or governmental sector are advised to undergo treatments in the main TB centers under direct observed treatment (DOT). TB patients should administrate the drug under DOT daily in intensive phase (I.P) and weekly in Continuous Phase. The treatment consists of an initial two month intensive phase of isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E), followed by a four month continuation phase of H and E [17]. The TB centers screen new TB patients on the basis of the guidelines of the Yemen National TB Control Program [17]. Given that the studies were conducted at the multicenter of the two major TB-prevalent cities in Yemen, the data were
Fig 1. Number of TB patients enrolled in the study. doi:10.1371/journal.pone.0156258.g001
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
collected by six trained pharmacists and nurse data collectors (three in each city). The patients who agreed to participate in the study were asked to sign an informed consent form after disclosing the clear purpose of the study. Certificates and permissions to use the SF-36V2 in Yemen were provided by Quality Metric Incorporated (USA). The data questionnaire consists of two parts. The first part explored the socio-demographical information of TB patients, including the stigma and knowledge questionnaire. Moreover, a separate questionnaire was used to collect clinical characteristics from patients’ records, such as cough history and type, x-ray report, comorbidity, and a number of clinical signs at the beginning of the treatment. The second part of the questionnaire included an Arabic HRQol version and an official translation made by Quality Metric Incorporated. The forward translations of questionnaires were performed in Sana’a University by a group of Arabic native speakers. Backward translations were performed by the UN Organization office in Sana’a for the purpose of conceptual equivalence. HRQols were validated, and the Cronbach’s alpha obtained was 0.70. The HRQoL questionnaire consists mainly of eight domains that reflect various aspects of the QoL of TB patients, including physical functioning, Vitality, physical role, bodily pain, general health, social functioning, emotional role, and mental health.
Statistical analysis Data analyses were performed using PASW (Predictive Analysis Software, version 22, IBM Corp, Armonk, NY). The physical component score (PCS) and mental component score (MCS) were calculated using QM scoring software version 4.5 [21]. MCS and PCS were used as continuous variables for mean and standard deviation calculations. Furthermore, the other categorical variables were represented as percentage and counts. The scores of both health domains were considered normal if they are between 47 to 53. Scores below 47 were considered a sign of defective function [20], [7]. Moreover, a score of 45
15 (6.2)
45
228 (93.8) 243(100)
Governance Taiz
144 (59.3)
Alhodiah
99 (40.7) 243(100)
Area € Urban
168 (69.1)
Rural
75 (30.9) 243(100)
Marital status Married
112 (46.1)
Non-married
131 (53.9) 243(100)
Occupation (Continued)
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
Table 1. (Continued) Tuberculosis features
Patient n (%)
Employed
125 (51.4)
Non Employed
118 (48.6) 243(100)
Income (Rial) ° 10,000 or don’t have
135 (55.6)
>10,000
108 (44.4) 243(100)
Smoking status Smoker
68 (28)
Non smoker
175 (72) 243(100)
Chewing khat ǂ Yes
152 (62.6)
No
91 (37.4) 243(100)
Stigma Yes
99 (40.7)
No
144 (59.3) 243(100)
Knowledge Poor
21 (8.6)
Good
222 (91.4) 243(100)
Family history of TB Yes
74 (30.5)
No
169 (69.5) 243(100)
BMI z < 18.5 kg/m2
108 (44.4)
18.5 kg/m2
135 (55.6)
BCG Yes
63 (25.9)
No
180 (74.1) 243(100)
History contacts with TB Patient Yes
31 (12.8)
No
212 (87.2) 243(100)
Primary Education Yes No
90 (37) 1 153 (63) 243(100)
P.Secondary Education ‴ Yes
59 (24.3) 3
No
184 (75.7) (Continued)
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
Table 1. (Continued) Tuberculosis features
Patient n (%) 243(100)
Secondary Education Yes
71 (29.2) 2
No
172 (70.8) 243(100)
University Yes
23 (9.5) 4
No
220 (90.5) 243(100)
¶
EPTB: Extra Pulmonary Tuberculosis
€
Area: Governance ° Rial: Yemen’s currency ǂ
khat: shrub that grows in parts of East Africa and Yemen
z-
BMI: Body Mass Index > I.P: Intensive Phase
Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen Ammar Ali Saleh Jaber*, Amer Hayat Khan, Syed Azhar Syed Sulaiman, Nafees Ahmad, Mohamed Saif Anaam Department of Clinical Pharmacy, School of Pharmaceutical Sciences, USM, Penang, Malaysia * [email protected]
Abstract a11111
Background The health-related quality of life (HRQoL) of Tuberculosis (TB) patients is important because it directly influences the outcome of TB patients in several aspects. The current study aims to evaluate and to find the factors influencing the HRQoL of TB patients in two major TB-prevalent cities (Taiz and Alhodidah) in Yemen.
OPEN ACCESS Citation: Jaber AAS, Khan AH, Syed Sulaiman SA, Ahmad N, Anaam MS (2016) Evaluation of HealthRelated Quality of Life among Tuberculosis Patients in Two Cities in Yemen. PLoS ONE 11(6): e0156258. doi:10.1371/journal.pone.0156258 Editor: Seyed Ehtesham Hasnain, Indian Institute of Technology Delhi, INDIA Received: February 21, 2016 Accepted: May 11, 2016
Methods A prospective study was conducted, and all TB patients meeting the HRQoL criteria were asked to complete the HRQoL SF-36 survey. The records of TB patients were examined for disease confirmation, and a follow-up was consequently performed for patients during treatment between March 2013 and February 2014 in Taiz and Alhodidah Cities. HRQol scores were calculated by using QM scoring software version 4.5, in which the physical component score (PCS) and mental component score (MCS) were obtained. The scores obtained between 47–53 normal based score (NBS) were considered equivalent to the US normal score. Low scores indicate the poor health situation of TB patients
Published: June 3, 2016 Copyright: © 2016 Jaber et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: The authors have no support or funding to report. Competing Interests: The authors have declared that no competing interests exist.
Results A total of 243 TB patients enrolled in the study at the beginning of the treatment. A total of 235 and 197 TB patients completed the questionnaire at the end of the intensive phase (I. P.) and continuation phase (C.P.), respectively. The final dropout rate was 16.2%. The mean PCS and MCS scores at the beginning of treatment were low, thus showing the poor health situation of TB patients. The mean PCS scores at the beginning of treatment, end of I.P., and end of treatment were (36.1), (44.9), and (48), respectively. Moreover, the mean MCS score at the beginning of treatment, end of I.P., and end of treatment were (35.1), (42.2), and (44.3), respectively. The result shows that significant increases are observed at the end of I.P. for PCS and MCS because of the treatment and slight changes at the end of C.P. Despite this finding, the MCS score remains below the normal range (47), thus
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
1 / 19
Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
indicating a significant risk of depression among TB patients. Furthermore, general linear repeated measure ANOVA was performed for selected variables, to examine the changes of PCS and MCS over time. It was found that Alhodiah city, chewing khat habit, stigmatization, and duration of treatment more than six months were greatly associated with low mean MCS score of TB patient, indicating great risk of depression which may result in poor treatment outcome.
Conclusion TB patients in Yemen were found to have poor QoL, with a significant likelihood of depression. Highly risk depression was found among TB patients in Alhodiah city, khat chewers, stigmatization and having a duration of treatment more than 6 months. Therefore, additional efforts should be made to improve their QoL because it may affect the final clinical outcome of patients.
Introduction SF-36V2 health-related quality of life (HRQoL) is a generic self-reported questionnaire that is used to determine the quality of life (QoL) of the general population or individual patients [1]. Moreover, it is used to measure the influence and effects of the disease on patient functions and activities [2]. HRQoL acts as a predictor of patient therapy [3] by giving the health worker the characteristic changes of morbidity at a particular time and helping predict the factors that improve patient satisfaction [4] [5]. Several studies were conducted in different regions and countries to assess and evaluate the effect of tuberculosis (TB) on patients’ QoL [6], [7], [8],[9], [10]. Only a few studies have investigated TB at various treatment stages [11], [12], [9]. HRQoL evaluation is important because it predicts the change of health conditions of subjects at various levels of treatment and eventually affect the treatment outcome of TB patients [3], [4]. TB is considered a major disease, which impairs the daily life activities of the patient. The effect of TB on a patient’s health is considered essential [13] because, it can result to changes in the physical and mental states of the patient, and can consequently affect the treatment outcome [14]. Moreover, even less attention is given to QoL in developing countries as an influential factor, especially in TB disease [15]. WHO recognizes Yemen as an intermediate TB-burdened country [16]. TB in Yemen is considered one of the main health problems and ranks fourth in the priority list of public health issues [17]. In Yemen, the people’s standard QoL is considered low because of poverty, low life standard, and weak governmental health services [18], [19]. However, no study has performed HRQol for TB patients by using SF36 in the two major TB-prevalent cities in Yemen. This study aims to evaluate the HRQoL of TB patients in the two major TB-prevalent cities in Yemen for one year and to find the factors affecting the quality of life of TB patient during the treatment period.
Study Population and Methods This prospective study was conducted at the multicenter of the two major TB-prevalent cities in Yemen (Taiz and Alhodidah) under the National TB Control Program. Taiz City is located approximately 256 km south of Sana’a. Taiz holds the first rank regarding the number of
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
2 / 19
Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
population, with a population representing 12.16% of the total population of Yemen. AlHodeida City is located in the Red Sea Coast at a distance of 226 km from Sana’a; this city ranks second in terms of the number of population, with a population representing nearly 11% of the total population of the republic [17]. All the patients registered between March 2013 and February 2014, met the HRQoL criteria (18 years old and literate) [20], and confirmed their TB diagnosis upon enrollment in the study. Patients who defaulted, died, transferred out, and refused to participate were excluded from the study (Fig 1). In Yemen, all TB patients who underwent diagnosed either in the private or governmental sector are advised to undergo treatments in the main TB centers under direct observed treatment (DOT). TB patients should administrate the drug under DOT daily in intensive phase (I.P) and weekly in Continuous Phase. The treatment consists of an initial two month intensive phase of isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E), followed by a four month continuation phase of H and E [17]. The TB centers screen new TB patients on the basis of the guidelines of the Yemen National TB Control Program [17]. Given that the studies were conducted at the multicenter of the two major TB-prevalent cities in Yemen, the data were
Fig 1. Number of TB patients enrolled in the study. doi:10.1371/journal.pone.0156258.g001
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
3 / 19
Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
collected by six trained pharmacists and nurse data collectors (three in each city). The patients who agreed to participate in the study were asked to sign an informed consent form after disclosing the clear purpose of the study. Certificates and permissions to use the SF-36V2 in Yemen were provided by Quality Metric Incorporated (USA). The data questionnaire consists of two parts. The first part explored the socio-demographical information of TB patients, including the stigma and knowledge questionnaire. Moreover, a separate questionnaire was used to collect clinical characteristics from patients’ records, such as cough history and type, x-ray report, comorbidity, and a number of clinical signs at the beginning of the treatment. The second part of the questionnaire included an Arabic HRQol version and an official translation made by Quality Metric Incorporated. The forward translations of questionnaires were performed in Sana’a University by a group of Arabic native speakers. Backward translations were performed by the UN Organization office in Sana’a for the purpose of conceptual equivalence. HRQols were validated, and the Cronbach’s alpha obtained was 0.70. The HRQoL questionnaire consists mainly of eight domains that reflect various aspects of the QoL of TB patients, including physical functioning, Vitality, physical role, bodily pain, general health, social functioning, emotional role, and mental health.
Statistical analysis Data analyses were performed using PASW (Predictive Analysis Software, version 22, IBM Corp, Armonk, NY). The physical component score (PCS) and mental component score (MCS) were calculated using QM scoring software version 4.5 [21]. MCS and PCS were used as continuous variables for mean and standard deviation calculations. Furthermore, the other categorical variables were represented as percentage and counts. The scores of both health domains were considered normal if they are between 47 to 53. Scores below 47 were considered a sign of defective function [20], [7]. Moreover, a score of 45
15 (6.2)
45
228 (93.8) 243(100)
Governance Taiz
144 (59.3)
Alhodiah
99 (40.7) 243(100)
Area € Urban
168 (69.1)
Rural
75 (30.9) 243(100)
Marital status Married
112 (46.1)
Non-married
131 (53.9) 243(100)
Occupation (Continued)
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
Table 1. (Continued) Tuberculosis features
Patient n (%)
Employed
125 (51.4)
Non Employed
118 (48.6) 243(100)
Income (Rial) ° 10,000 or don’t have
135 (55.6)
>10,000
108 (44.4) 243(100)
Smoking status Smoker
68 (28)
Non smoker
175 (72) 243(100)
Chewing khat ǂ Yes
152 (62.6)
No
91 (37.4) 243(100)
Stigma Yes
99 (40.7)
No
144 (59.3) 243(100)
Knowledge Poor
21 (8.6)
Good
222 (91.4) 243(100)
Family history of TB Yes
74 (30.5)
No
169 (69.5) 243(100)
BMI z < 18.5 kg/m2
108 (44.4)
18.5 kg/m2
135 (55.6)
BCG Yes
63 (25.9)
No
180 (74.1) 243(100)
History contacts with TB Patient Yes
31 (12.8)
No
212 (87.2) 243(100)
Primary Education Yes No
90 (37) 1 153 (63) 243(100)
P.Secondary Education ‴ Yes
59 (24.3) 3
No
184 (75.7) (Continued)
PLOS ONE | DOI:10.1371/journal.pone.0156258 June 3, 2016
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Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen
Table 1. (Continued) Tuberculosis features
Patient n (%) 243(100)
Secondary Education Yes
71 (29.2) 2
No
172 (70.8) 243(100)
University Yes
23 (9.5) 4
No
220 (90.5) 243(100)
¶
EPTB: Extra Pulmonary Tuberculosis
€
Area: Governance ° Rial: Yemen’s currency ǂ
khat: shrub that grows in parts of East Africa and Yemen
z-
BMI: Body Mass Index > I.P: Intensive Phase
