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BACKGROUND: We investigated health-related quality of life (HrQoL) in Filipino people undergoing TB treatment, and whether HrQoL was negatively impacted by comorbidity with undernutrition, diabetes (DM) and anaemia. METHODS: Adult participants were enrolled in public facilities in Metro Manila (three sites) and Negros Occidental (two sites). Multivariate linear regression was used to model the four correlated domain scores from a WHOQOL-BREF questionnaire (physical, psychological, social, environmental). A forward-stepwise approach was used to select a final multivariable model with inclusion based on global tests of significance at P < 0.1. RESULTS: In 446 people on drug-susceptible TB treatment, DM and moderate/severe anaemia were not associated with HrQoL. After adjustment for age, sex, education, food insecurity, treatment adherence, inflammation, Category I or II TB treatment, treatment phase, current side effects and inhibited ability to work, moderate/severe undernutrition (body mass index < 17 kg/m ² ) was associated with lower HrQoL ( P = 0.003) with reduced psychological (coefficient: −1.02, 95% CI −1.54 to −0.51), physical (−0.62, 95% CI −1.14 to −0.09) and environmental domain scores (−0.45, 95% CI −0.88 to −0.01). In 225 patients with known HIV status in Metro Manila, HIV was associated with modestly reduced HrQoL ( P = 0.014). CONCLUSION: Nutritional status and food insecurity represent modifiable risk factors for poor HrQoL that may be alleviated through interventions.
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INT J TUBERC LUNG DIS 24(7):712–719
2020 The Union
Effects of comorbidities on quality of life in Filipino people with
T. Edwards,
L. V. White,
N. Lee,
M. C. Castro,
N. R. Saludar,
B. N. Faguer,
N. D. Fuente,
F. Mayoga,
K. Ariyoshi,
A. M. C. G. Garfin,
J. A. Solon,
S. E. Cox
Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine (LSHTM), London, UK;
School of
Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan;
Royal Free Hospital, London, UK;
Nutrition Center Philippines, Manila,
San Lazaro Hospital, Manila,
Valladolid Health Center, Valladolid, Negros
Bago City Health Center, Bago City, Negros Occidental, the Philippines;
Institute of Tropical Medicine,
Nagasaki University, Nagasaki, Japan;
National TB Control Programme, Department of Health, Manila, the
Faculty of Population Health, LSHTM, London, UK
BACKGROUND: We investigated health-related quality
of life (HrQoL) in Filipino people undergoing TB
treatment, and whether HrQoL was negatively impacted
by comorbidity with undernutrition, diabetes (DM) and
METHODS: Adult participants were enrolled in public
facilities in Metro Manila (three sites) and Negros
Occidental (two sites). Multivariate linear regression was
used to model the four correlated domain scores from a
WHOQOL-BREF questionnaire (physical, psychological,
social, environmental). A forward-stepwise approach was
used to select a final multivariable model with inclusion
based on global tests of significance at P
RESULTS: In 446 people on drug-susceptible TB treat-
ment, DM and moderate/severe anaemia were not
associated with HrQoL. After adjustment for age, sex,
education, food insecurity, treatment adherence, inflam-
mation, Category I or II TB treatment, treatment phase,
current side effects and inhibited ability to work,
moderate/severe undernutrition (body mass index
17 kg/m
) was associated with lower HrQoL (P
with reduced psychological (coefficient: 1.02, 95% CI
1.54 to 0.51), physical (0.62, 95% CI 1.14 to
0.09) and environmental domain scores (0.45, 95%
CI 0.88 to 0.01). In 225 patients with known HIV
status in Metro Manila, HIV was associated with
modestly reduced HrQoL (P
CONCLUSION: Nutritional status and food insecurity
represent modifiable risk factors for poor HrQoL that
may be alleviated through interventions.
KEY WORDS: tuberculosis; diabetes; malnutrition;
comorbidities; the Philippines; quality of life
morbidity in many high-burden countries.
increasing attention is being paid to the impact of TB
beyond physical health, including psychosocial and
financial impacts, the effects of common comorbid-
ities such as HIV, diabetes (DM), acute malnutrition
and anaemia on the patient’s overall well-being is not
Understanding how TB impacts on quality of life
(QoL) as perceived by individuals, is important for
understanding how to improve patient-centred care
(a component of Pillar 1 in the End TB Strategy
It is also needed to evaluate interventions and
for health policy, since data on health-related QoL
(HrQoL) are used in health economic evaluations.
HrQoL encompasses the physical, mental and social
well-being of individuals. How these are perceived is
dependent on the society and environment of
individuals. Studies in a range of settings have
reported negative impacts of TB disease on an
individual’s HrQoL, using an assortment of mostly
generic tools applicable to different health conditions.
Some of these studies included an appropriate
comparison population groups of individuals without
TB disease or with latent TB infection or reference
population norms.
Few studies in people with
active TB disease have included an assessment of the
impact of comorbidities on HrQoL, although a recent
prospective cohort study in India reported a negative
effect of DM using the TB-specific Dhingra and
Rajpal (DR-12) scale.
Although the Philippines has a high TB burden, there
are currently limited HrQoL data from the Philippines
or on comorbidities in TB. Within a cross-sectional
study of Filipino people with active TB disease enrolled
in TB-DOTS clinics (ISRCTN12506117), we investi-
Correspondence to: Sharon Cox, Faculty of Population Health, London School of Hygiene & Tropical Medicine, Keppel
Street, London WC1E 7HT, UK; and School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4
Sakamoto, Nagasaki 852-8523, Japan e-mail:;
Article submitted 27 November 2019. Final version accepted 3 February 2020.
gated, as a primary objective, the prevalence of DM and
moderate/severe acute undernutrition and factors asso-
ciated with these comorbidities, reported elsewhere.
Here, we report into whether comorbidities of under-
nutrition, DM and moderate or severe anaemia and
HIV infection are associated with reduced HrQoL in
this population, as a secondary objective.
Study design
This was a cross-sectional survey, described in detail
Study setting
The Philippines is a middle-income country, estimat-
ed to have the third highest TB incidence (554/
100 000 population) occurring in the context of a low
HIV prevalence, estimated at 2% of incident TB
cases, although HIV testing is low in many areas.
The prevalence of undernutrition (body mass index
[BMI] ,18.5 kg/m
) in Filipino adults was 10% in
the 2014 National Nutrition Survey. Three public TB-
DOTS clinics in Metro Manila provided data from an
urban setting, including the TB-DOTS Clinic at San
Lazaro Hospital, an infectious disease referral hospi-
tal, serving a predominantly poor population. Metro
Manila is identified as a Category ‘A’ area, with a
high burden of HIV compared to other areas of the
country. Two public TB-DOTS clinics in Negros
Occidental provided data from a rural setting.
Adults (aged 18 years, excluding pregnant women)
whose TB-DOTS registration date indicated that TB
treatment should be ongoing, were eligible to
participate. Research nurses visited barangays (vil-
lages) to attempt to locate all those whose treatment
was ongoing.
The primary outcome of interest was HrQoL assessed
using the World Health Organisation Quality of Life-
BREF (WHOQOL-BREF) assessment,
. Responses
to 24 of the 26 items in WHO HrQoL-BREF were
used to score four domains: 1) physical, 2) psycho-
logical, 3) social relationships, and 4) environment.
Domain scores were calculated according to the
standard algorithm (with a possible range of 4–20).
Higher domain scores reflect better HrQoL.
Data collection and definitions of comorbidity
Trained multilingual research nurses completed all
study assessments using questionnaires and tools
translated into local languages and extracted infor-
mation recorded on participant’s National TB Pro-
gram treatment cards. Household food security was
assessed using the Adapted US Household Food
Security Survey Module (US HFSSM), previously
validated for use in the Philippines.
Data were
entered directly into Open Data Kit software and
uploaded to a secure server daily. Research nurses
conducted anthropometry measurements;
weight to
the nearest 0.1 kg; height, mid-upper arm circumfer-
ence (MUAC) and waist and hip circumferences to
the nearest 0.5 cm; and grip strength to the nearest kg
(Jamar Hydraulic Hand Dynamometer; Lafayette
Instruments, IN, USA) using the highest of three
measurements of the dominant hand. Fingerprick
blood samples were used to obtain haemoglobin
(HemoCue 301; ¨
Angelholm, Sweden), glycosylated
haemoglobin (HbA1C) and C-reactive protein (CRP)
(Alere Afinion AS100 Analyzer; Abbott Diagnostics,
Abbott Park, IL, USA) and to conduct HIV screening
(Standard Diagnostics Bioline HIV-1/2 Ag/Ab Combo
Rapid Test kits) for those with unknown status and
who provided additional consent.
Comorbid conditions considered here included
undernutrition, defined as moderate/severe undernu-
trition (BMI ,17.0 kg/m
), DM defined as HBA1c
6.5% or receiving treatment for DM at enrolment,
moderate/severe anaemia defined as haemoglobin ,
11 g/dL. HIV co-infection was defined as a positive
screening test result or a previous diagnosis. Other
available data included 1) sociodemographic charac-
teristics: age, sex, urban/rural area study area, marital
status, level of education, distance/time to TB-DOTS
centre, health insurance, level of household food
security, smoking and alcohol consumption and
factors relating to impact of TB on ability to work
and cover expenses; 2) health and TB related factors:
TB category (new vs. relapse etc.), phase of TB
treatment (intensive vs. continuation), current side
effects of TB treatment, adherence to TB treatment in
the previous week, category of medication (Category
I or II), presence of inflammation (CRP .5 g/L) and
hand grip strength as a measure of functional
nutritional status.
Sample size
Sample size for this study was determined by the main
study of undernutrition and DM comorbidity. Of 614
participants with drug-susceptible TB in the main
study, 446 completed QoL interviews.
Statistical methods
Data were analysed using Stata v.15.1 (Stata Corp,
College Station, TX, USA) and R (R Computing,
Vienna, Austria).
Characteristics were summarised
for all enrolled participants and for those with
complete HrQoL data. Physical, psychological, social
and environmental domain scores were summarised
as mean (standard deviation [SD]), after observing
data to be approximately normally distributed.
Due to correlation between QoL domain scores
Comorbidities and quality of life in TB 713
within individuals, multivariate linear regression was
used to simultaneously analyse the four QoL out-
comes in the same model. For each independent
variable, regardless of the number of categories,
global tests of association were conducted for
association with the four domains to reduce multiple
Multivariable multivariate linear regression model
building was carried out using a forward stepwise
approach in blocks of related exposures, where
blocks comprised 1) comorbidities, 2) demographic
and socioeconomic indicators, and, 3) TB related
factors. Variables were retained if the global test of
association Pvalue after adjustment for other
variables was ,0.1. Sex was included a priori.In
the final adjusted model, the strength of association
between the independent variables and QoL domain
scores was interpreted with and without Bonferroni’s
adjustment for the number of tests of association in
the final model (a¼0.05/number of tests of
association [covariates] in the final model).
Ethical approval was obtained from Institutional
Ethics Review Boards at School of Tropical Medicine
and Global Health, Nagasaki University (Nagasaki,
Japan), London School of Hygiene & Tropical
Medicine (London, UK), Philippines National Ethics
Committee (Manila, The Philippines) and San Lazaro
Hospital in Manila. Written consent was provided by
all participants prior to study enrolment, and
additional written consent was obtained for HIV
screening in accordance with Department of Health
Of 614 participants on non-drug-resistant TB regi-
mens enrolled between 8 May and 18 September
2017, 446 were interviewed for HrQoL between 19
May and 18 September 2017. The 446 participant
sub-set included in this analysis (hereafter referred to
as the study population) were similar to the total
study population, except that a greater proportion of
those with HrQoL data were enrolled in urban Metro
Manila than in rural Negros Occidental (Supplemen-
tary Table S1). Males comprised 70% of the study
population and the mean age was 44.8 years (SD
16.7). Participants were significantly older in Negros
Occidental than in Metro Manila (50.5 vs. 41.1 years;
P,0.001), with no difference in age by sex (P¼
0.280). The proportion of participants with previ-
ously treated TB (i.e., those programmatically de-
fined as relapse, treatment after failure, previous
treatment outcome unknown or treatment after loss
to follow-up) was 30.3% (134/443). There was no
evidence that the proportion of previously treated
cases differed by urban/rural area or by sex but did
increase with age, from 17.4% in the 18–40 years age
group, 40% in the 41–65 years’ age group to 45.6%
in the .65 years age group (P,0.001). This is
relevant, because previously treated cases in this
setting were treated with Category II TB treatment
including daily injectable streptomycin during the
intensive phase of treatment.
The prevalence of DM in the study population was
8.3%, with just over half newly captured by the study
protocol (Supplementary Table S1). The prevalence
of moderate and severe undernutrition was 19.7%,
moderate/severe anaemia was 15.7% and self-report-
ed hypertension was 9.0% (Supplementary Table S1).
HIV status was unknown for the majority of
participants in Negros Occidental due to screening
refusal. In Metro Manila, HIV status was known for
238 (88%) of participants, and 68 (28.6%) were
infected. All but 4 had been previously diagnosed,
and 54 were on antiretroviral therapy. Most of these
participants (63/68) were enrolled at San Lazaro
Hospital, an HIV referral centre, accounting for the
high proportion of HIV comorbidity in our urban
study population.
Data were complete for all items on the WHO-
QOL-BREF. Domain scores were approximately
normally distributed, although some skew and
outliers were noted for the psychological domain
(Figure 1). Internal consistency across domain com-
ponents was good for the physical, psychological and
environmental domains (Cronbach’s a.0.7), but
poor for the social relationships’ domain (Cronbach’s
For the single (national item) of overall rating of
QoL, 98 (22.0%) rated their QoL as poor or very
poor, and 160 (35.9%) as good or very good. This
compared to 169 (37.9%) who reported being
dissatisfied or very dissatisfied with their health and
118 (26.5%) who were satisfied or very satisfied.
Mean domain scores are shown in Tables 1, S2 and
S3. In univariable, multivariate analysis there was no
evidence of an association between DM, anaemia or
reported hypertension with HrQoL domain scores
(Table 1). However, moderate/severe undernutrition
was significantly associated (P,0.001) with reduced
scores for the physical and psychological domains.
Similarly, grip strength as a measure of functional
nutritional status was positively associated with
higher domain scores (P,0.001), while moderate
and severe levels of household food insecurity were
associated with reduced scores (P,0.001; Supple-
mentary Table S2). For those with known HIV status
in Metro Manila, HIV infection was associated with
HrQoL domain scores (P,0.001; Table 1), with
evidence of increased scores for the physical and
environmental domains. We also assessed associa-
tions with indicators of the possible impact of TB on
ability to work, and consequences for household
finances, which both showed evidence of negatively
714 The International Journal of Tuberculosis and Lung Disease
affecting HrQoL scores (P,0.001; Supplementary
Table S2). Finally, TB-specific factors were assessed,
all of which, apart from the basis of diagnosis
(bacteriological vs. clinical) were significantly asso-
ciated (Supplementary Table S3).
Effects for factors retained in the final model are
shown in Table 2.The association between HrQoL
and undernutrition remained after adjustment for
other exposures, with the greatest reduction in the
psychological domain. Moderate or severe food
insecurity showed a dose-response effect of decreased
scores for all domains (Figure 2A). When considering
a Bonferroni adjustment to account for 12 global tests
(aof 0.05/12 ¼0.004), undernutrition and household
food security remained strongly associated with
When adjusting for area in the model (P,0.001),
effects of adherence and undernutrition were reduced
(global test P¼0.078 and P¼0.058), as these differed
by area (93% in Negros Occidental adhered fully in
Figure 1 Distribution of health-related quality of life domain scores in persons on drug-
susceptible tuberculosis treatment regimens.
Table 1 Domain scores in 446 persons on drug-susceptible TB treatment regimens by clinical comorbid characteristics
Health-related quality of life domain, mean (SD) Global
PvaluePhysical Psychological Social Environmental
Overall 446 13.4 (2.4) 13.7 (2.2) 14.6 (2.0) 13.3 (2.0)
Undernutrition None/mild: BMI ,17 kg/m
357 13.7 (2.3) 13.8 (2.1) 14.7 (1.9) 13.4 (2.0) ,0.001
Moderate/severe: BMI 17 kg/m
88 12.6 (2.5) 12.9 (2.2) 14.5 (2.3) 13.0 (1.9)
Anaemia None/mild: Hb 11 g/dL 373 13.5 (2.4) 13.8 (2.2) 14.7 (2.0) 13.4 (1.9) 0.182
Moderate/severe: Hb ,11 g/dL 70 13.0 (2.4) 13.1 (2.2) 14.3 (2.0) 12.9 (2.0)
Diabetes No: HbA1c ,6.5%, not on treatment 409 13.5 (2.4) 13.7 (2.2) 14.6 (2.0) 13.3 (2.0) 0.590
Yes: HbA1c 6.5% or on treatment 37 13.2 (2.3) 13.6 (2.2) 14.9 (1.8) 13.6 (1.5)
Diabetes diagnosis Not diabetic 409 13.5 (2.4) 13.7 (2.2) 14.6 (2.0) 13.3 (2.0) 0.773
New diagnosis (HbA1c 6.5%,
no previous diagnosis)
19 13.1 (2.2) 13.8 (1.7) 15.2 (1.4) 13.5 (1.6)
Existing diagnosis 18 13.4 (2.5) 13.4 (2.6) 14.6 (2.1) 13.6 (1.5)
Diabetes control Not diabetic 409 13.5 (2.4) 13.7 (2.2) 14.6 (2.0) 13.3 (2.0) 0.570
Controlled: on treatment and
HbA1c ,8.0%
14 13.9 (2.6) 14.0 (2.4) 14.7 (2.0) 13.6 (1.6)
Uncontrolled: HbA1c 8% 23 12.8 (2.0) 13.4 (2.0) 15.1 (1.7) 13.5 (1.5)
Self-reported hypertension No 406 13.5 (2.4) 13.7 (2.2) 14.7 (2.0) 13.4 (2.0) 0.072
Yes 40 12.4 (2.1) 13.2 (2.0) 14.3 (1.9) 12.7 (1.9)
Number of comorbidities
(undernutrition, anaemia,
diabetes, hypertension)
0 262 13.8 (2.4) 14.0 (2.1) 14.8 (1.9) 13.5 (2.0) 0.004
1 137 13.3 (2.4) 13.3 (2.3) 14.5 (2.2) 13.3 (1.9)
2 43 12.1 (1.9) 12.9 (1.9) 14.4 (1.9) 12.6 (1.8)
3 4 12.1 (3.8) 12.3 (2.5) 14.7 (1.9) 12.5 (2.0)
Inflammation No: C-reactive protein ,5 g/L 369 13.7 (2.4) 13.8 (2.2) 14.7 (2.1) 13.4 (2.0) 0.010
Yes: C-reactive protein 5 g/L 34 12.3 (2.6) 12.6 (1.9) 13.7 (1.8) 12.6 (1.8)
Hand grip strength, kg 445 ,0.001
HIV infection (Manila only) No 170 13.5 (2.5) 14.2 (2.1) 14.8 (2.1) 13.1 (2.0) ,0.001
Yes 68 14.5 (1.7) 14.2 (1.9) 14.8 (1.8) 14.7 (1.5)
TB¼tuberculosis; SD ¼standard deviation; BMI¼body mass index; Hb ¼haemoglobin; HbA1c¼glycosyla ted haemoglobin; HIV¼human immunodeficiency virus.
Comorbidities and quality of life in TB 715
Table 2 Multivariable multivariate regression analysis in 392 persons on drug-susceptible TB treatment regimens*
Health-related quality of life domain, linear regression coefficient (95% CI)
Physical Psychological Social Environmental Global Pvalue
Sex Female
Male –0.88 (–1.44 to –0.32)
–0.42 (–0.97 to 0.13) –0.14 (–0.68 to 0.39) –0.21 (–0.68 to 0.25) 0.039
Age, years 18–40
41–65 –0.18 (–0.70 to 0.33) –0.50 (–1.00 to 0.01) –0.19 (–0.68 to 0.30) –0.48 (–0.90 to -0.05)
.65 –0.75 (–1.54 to 0.04) –0.96 (–1.74 to –0.18)
–0.82 (–1.57 to –0.06)
–0.48 (–1.14 to 0.18)
Maximum education obtained Primary
Secondary 0.42 (–0.11 to 0.95) 0.42 (–0.10 to 0.94) 0.24 (–0.26 to 0.75) 0.39 (–0.05 to 0.83) ,0.001
Tertiary 1.01 (0.35 to 1.66)
0.40 (–0.24 to 1.04) –0.10 (–0.72 to 0.52) 1.20 (0.66 to 1.74)
Vocational 0.13 (–1.24 to 1.49) –0.62 (–1.96 to 0.72) 0.07 (–1.23 to 1.37) 0.49 (–0.64 to 1.62)
Household food security Secure
Moderate insecurity –0.66 (–1.20 to –0.12)
–0.57 (–1.10 to –0.03)
–0.64 (–1.16 to –0.12)
–0.93 (–1.38 to –0.48)
Severe insecurity –0.78 (–1.35 to –0.22)
–0.82 (–1.38 to –0.27)
–1.00 (–1.53 to –0.46)
–1.25 (–1.71 to –0.78)
Moderate/severe undernutrition
No: BMI ,17 kg/m
Yes: BMI 17 kg/m
–0.62 (–1.14 to –0.09)
–1.02 (–1.54 to –0.51)
–0.20 (–0.70 to 0.30) –0.45 (–0.88 to –0.01)
Inflammation No: CRP ,5g/L
Yes: CRP .5 g/L –0.96 (–1.73 to –0.19)
–1.14 (–1.90 to –0.39)
–0.97 (–1.71 to –0.24) –0.90 (–1.54 to –0.27)
Hand grip strength 0.05 (0.02 to 0.08)
0.00 (–0.03 to 0.03) –0.00 (–0.03 to 0.03) –0.01 (–0.03 to 0.01) ,0.001
Phase of treatment Intensive
Continuation 0.51 (0.06 to 0.97)
0.28 (–0.16 to 0.73) –0.09 (–0.52 to 0.34) –0.14 (–0.51 to 0.24) 0.025
TB treatment category Category 1
Category 2 –0.65 (–1.11 to –0.19)
–0.46 (–0.92 to –0.01)
–0.75 (–1.19 to –0.31)
–0.22 (–0.60 to 0.17) 0.002
Current treatment side effects No
Yes 0.76 (0.30 to 1.22)
0.41 (–0.04 to 0.86) 0.16 (–0.27 to 0.60) 0.41 (0.03 to 0.79)
Ability to work affected No
Yes –0.48 (–0.91 to –0.05)
–0.72 (–1.15 to –0.30)
–0.74 (–1.15 to –0.33
) –0.20 (–0.56 to 0.16) ,0.001
Number of days adherent in last 7 days 0.03 (–0.05 to 0.11) –0.06 (–0.14 to 0.02) 0.01 (–0.07 to 0.09) 0.10 (0.03 to 0.17)
* Based on n¼392 after exclusion of missing values (missing values: total ¼5; BMI ¼1; grip strength ¼1; work ability ¼2; adherence ¼4; CRP ¼43).
From multivariable multivariate linear regression.
Indicates 95% CIs excluding the null effect.
TB ¼tuberculosis; CI ¼confidence interval; BMI ¼body mass index; CRP ¼C-reactive protein.
716 The International Journal of Tuberculosis and Lung Disease
the last 7 days compared to 62% in Manila, v
0.001; and 30% vs. 15% severe/moderate undernu-
trition in Negros Occidental and Manila, P¼0.002).
Household food security was not associated with
undernutrition overall but did differ by area (approx-
imately two thirds moderate/severe food insecurity in
Negros compared to one third in Manila, P,0.001).
Undernutrition and recent adherence were retained in
the model over area as more specifically measured
covariates of interest.
The final model was fitted to participants from
Metro Manilla with known HIV status and non-
missing values for factors in the final model
(Supplementary Table S4). After adjustment, HIV
Figure 2 A) Adjusted effects on HrQoL domain scores in persons on drug-susceptible TB treatment regimens; B) adjusted effects on
HrQoL domain scores in persons on drug-susceptible TB treatment regimens registered in clinics in Metro Manilla with known HIV
status. Undernutrition: moderate/severe: BMI 17 kg/m
compared to mild/normal: BMI ,17 kg/m
; moderate and severe
household food insecurity compared to mild/no insecurity. Inflammation: CRP 5 g/L compared to CRP ,5 g/L. Category II compared
to Category I TB treatment regimen (Category II includes daily streptomycin injections in the intensive phase). HrQoL ¼health-related
quality of life; CRP ¼C-reactive protein.
Comorbidities and quality of life in TB 717
was associated with QoL overall (P¼0.014, Figure
2B) with the largest observed negative impact on
psychological domain, followed by environmental
domain. In this model, the effects of undernutrition
and adherence were absent, but food insecurity
remained a strong risk factor for reduced QoL (P,
0.001). In this sub-group, HIV was strongly associ-
ated with increased level of education (P,0.001),
which likely represents a proxy for socio-economic
status (60% of those with tertiary education had
HIV) and sex (40% of male participants vs. 3% of
women had HIV, P,0.001 and the previously
observed effect of sex on QoL was not seen in this
We focussed on the effect of DM and undernutrition
on HrQoL as more common comorbid conditions.
The prevalence of undernutrition is much higher than
in the general adult population (10% BMI ,18.5),
while the national prevalence of DM is estimated at
Furthermore, diagnosis and management of
DM and undernutrition are recommended for inte-
grated patient centred care, but current implementa-
tion is limited.
In this population, we observed that undernutrition
was independently associated with lower perceived
QoL in the physical, psychological and environmen-
tal domains. No effects were observed for DM or
anaemia. Furthermore, we explored if effects of DM
may be limited to those with existing diagnoses or
those with uncontrolled (HbA1c 8%) compared to
controlled DM, but saw no evidence of associations,
although low numbers of observations will have
limited the probability of detecting all but large
effects. In addition to undernutrition, household food
insecurity was associated in a dose-response manner
with reduced scores across all four domains. In a
previous cross-sectional study of HrQoL using the
Short Form-8 (a shorter version of the Short Form-36)
in 520 Filipino TB patients enrolled in TB-DOTS in
Metro Manila, the mental component summary
score, but not the physical component summary
score, was independently associated with increasing
Although the use of financial or in-kind
support for travel or food as incentives or enablers for
persons undergoing TB treatment are widely advo-
cated to increase treatment uptake and completion
and as means of poverty alleviation,
no such
programmes were available at the time of our study
for patients enrolled in non-MDR-TB treatment
regimens. Therefore, we could not investigate if such
provisions might impact QoL, and if mediated
through effects on nutritional status or household
food security. We are not aware of any studies that
have assessed this. In India, large increases in
WHOQOL-BREF domain scores were observed
between start of TB treatment and end of the
intensive phase and end of treatment.
The mean
scores at treatment completion were the most
comparable to those we observed (scores transformed
onto the 0–100 scale of 66 [environment domain] to
80 [physical domain]), equivalent to approximately
14.5 and 16.5 on the 4–20 scale we report). Over the
course of treatment, the largest improvement in QoL
was observed for the physical domain (nearly
doubled), but comorbidities were not assessed.
Another study in India (using the TB-specific Dhingra
& Rajpal DR-12 scale), reported decreased scores in
the socio-psychological and exercise adaptation
domains in persons with DM aged over 50 years;
while uncontrolled versus controlled DM was asso-
ciated with lower scores, but only at the end of TB
Despite a high prevalence of severe
undernutrition (23% BMI ,15 kg/m
), a possible
effect of this important comorbidity was not report-
Within our sub-set of participants with known
HIV status, living with HIV infection initially
appeared to be associated with increased QoL
domain scores, but after adjustment, this association
trended towards decreased scores, likely due to
confounding by age and education, which were
higher in those with HIV and also positively
associated with QoL domain scores, Thus, compared
to other studies in Ethiopia the impact of comorbid
HIV appeared to be limited.
As the majority of
those living with HIV were already in care at the same
site as their TB treatment and receiving antiretroviral
therapy, this suggests that in the context of adequate
care, the additional impact of comorbid HIV in TB is
not necessarily great. The level of impact may vary
depending on the extent of integrated management of
the two conditions and availability of coping/support
mechanisms for HIV care.
Although there is evidence that QoL scores increase
with duration of treatment, they may not resolve to
pre-disease levels due to the increasingly recognised
long-term effects of TB disease, including chronic
lung disorders, requiring long-term further manage-
Simple physical therapy rehabilitation inter-
ventions may be beneficial in improving lung function
and also QoL, especially in the physical domain.
Potential limitations of this study include the lack
of normative data in representative Filipino adults to
compare our observations with and low internal
consistency across the items in the social relation-
ships’ domain, so perhaps more contextual adapta-
tion of the tool is needed. Further limitations include
those inherent in cross-sectional studies. However,
selection bias was minimised by the inclusion of
participants across the range of treatment duration
and frequency of attending TB-DOTS clinics. Mea-
surement bias was minimised by trained study nurses
assessing nutritional status and screening of DM,
rather than relying on routinely collected data, but a
718 The International Journal of Tuberculosis and Lung Disease
single measurement of HbA1c 6.5% may have
resulted in misclassification of DM from temporary
glucose dysregulation induced by TB.
Evidence of the psychosocial effects of undernutri-
tion, additional to direct biomedical effects on TB
treatment outcomes provides further evidence to 1)
support the need for nutrition interventions; 2)
include additional outcomes such as HrQoL and
mental health-related measures to determine impacts
of nutrition interventions; and, 3) identify individuals
who might benefit from additional psychosocial
support. The measurement of household food inse-
curity within TB programmes may be a sensitive
indicator of household poverty and stress, which may
be alleviated through social protection mechanisms
aimed at the whole household and directly or
indirectly improving household food security and
potentially HrQoL.
The authors thank participants, their families, TB-DOTS clinic
staff and research nurses: AKQ Llantada, RMT Garcia, MA
Savaadra, CD Alvarez, RJ Juson and M Lourdes with support from
C Berido for their contributions in making this work possible.
Electronic data solutions were provided by London School of
Hygiene & Tropical Medicine Open Research Kits (London, UK)
This work was supported by funding from Nagasaki University
(Nagasaki, Japan) to SEC.
Conflicts of interest: none declared.
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Comorbidities and quality of life in TB 719
CONTEXTE : En raison de la faible quantit´e des donn´ees
existantes, nous avons ´evalu´e la qualit´e de vie li´ee `ala
sant´e (HrQoL) des Philippins suivant un traitement
antituberculeux ; et si ce dernier ´etait n ´egativement
affect´e par des comorbidit´es telles que la malnutrition, le
diab`ete et l’an´emie.
´THODES : Les participants adultes ont ´et´e recrut ´es
dans des ´etablissements publics du Grand Manille (3sites)
et de Negros occidental (2 sites). Nous avons utilis´eune
egression lin´eaire multivari´ee pour modeler les quatre
scores de domaine corr´el ´es du questionnaire
WHOQHOL-BREF (physique, psychologique, social,
environnemental). La m´ethode ascendante pas `a pas a
´et´e utilis´ee pour choisir un mod`ele multivari´e final avec
inclusion bas´ee sur des tests de signification dont P
´SULTATS : Chez 446 personnes sous traitement
contre la tuberculose pharmacosensible, le diab`ete et
l’an´emie mod´er´ee ou s´ev`ere n’ont pas ´et ´e associ ´es avec la
HrQoL. Apr`es pond ´eration de l’ ˆage, du sexe, du niveau
d’´education atteint, de l’ins´ecurit ´e alimentaire, de
l’adh´esion au traitement, de l’inflammation, de la
cat´egorie de traitement antituberculeux (I ou II), de la
phase de traitement, des effets secondaires
contemporains au traitement et r ´eduction de la
capacit´e`a travailler, la sous-nutrition mod´er´ee ou
ev`ere (indice de masse corporelle
17 kg/m
associ´ee `a une HrQoL plus faible (P
0.003) avec une
eduction des scores pour les domaines psychologiques
(coefficient 1,02 ; IC 95% 1,54 `a 0,51), physiques
(coefficient 0,62 ; IC 95% 1,14 `a0,09)et
environnementaux (coefficient 0,45 ; IC 95% 0,88 `a
0,01). Chez 225 patients du Grand Manille dont le statut
VIH ´etait connu, la s ´eropositivit ´ea´et ´e associ ´e avec une
HrQoL mod´er´ement r´eduite (P
CONCLUSIONS : Le statut nutritionnel et l’ins´ecurit´e
alimentaire repr´esentent des facteurs de risques ´evitables
vis-`a-vis de la HrQoL qui peuvent att´enu´es au travers
MARCO DE REFERENCIA: Dada la escasez de datos, se
investig ´o la calidad de vida relacionada con la salud
(HrQoL) en las personas de Filipinas que recib´ıan
tratamiento contra la TB y si una comorbilidad por
desnutrici ´on, diabetes o anemia la afectaban de manera
´TODOS: Los adultos participantes se inscribieron en
establecimientos p ´ublicos en Gran Manila (tres centros)
y en Negros Occidental (dos centros). Mediante una
regresi ´on lineal multivariante se modelizaron las
correlaciones de las puntuaciones de las cuatro
dimensiones del cuestionario WHOQOL-BREF (f´ısica,
psicol ´ogica, social y ambiental). Se utiliz ´ounm´etodo de
regresi ´on escalonada anter ´ograda a fin de escoger un
modelo multivariante final con inclusiones basadas en
las pruebas generales de significaci ´on con P
RESULTADOS: De 446 personas en tratamiento por TB
farmacosensible, la presencia de diabetes y anemia
moderada o grave no se relacion ´o con la HrQoL. Tras
corregir con respecto a la edad, el sexo, el grado de
instrucci ´on, la inseguridad alimentaria, el cumplimiento
terap´eutico, la inflamaci ´on, la Categor´ıa I o II del
tratamiento antituberculoso, la fase del tratamiento, los
efectos secundarios actuales y la alteraci ´on de la
capacidad de trabajar, se observ ´o que la desnutrici ´on
moderada o grave (´ındice de masa corporal
17 kg/m
se relacionaba con una HrQoL inferior (P
0,003), con
disminuci ´on de la puntuaci ´on de la esfera psicol ´ogica
(coeficiente –1,02; IC 95% –1,5 a 0,51), f´ısica (–0,62;
–1,14 a 0,09) y ambiental (–0,45; –0,88 a 0,01). De 225
pacientes con situaci ´on conocida frente al virus de la
inmunodeficiencia humana (VIH) en Gran Manila, la
infecci ´on por el VIH se asoci ´o con una leve disminuci ´on
de la HrQoL (P
´N: El estado nutricional y la inseguridad
alimentaria representan factores de riesgo modificables
de una HrQoL deficiente, que se pueden mejorar con las
Comorbidities and quality of life in TB i
... Studies have found that comorbidities such as undernutrition or diabetes mellitus (DM) impact the TB care cascade [76,77]. For other diseased conditions, comorbidities or concomitant treatment is prognostic of lower QoL scores, especially in the physical domain [48]. ...
... TB co-infection worsens the symptoms of HIV and advances the disease to the next stage, which can further deteriorate the HRQoL [70]. Additionally, studies have found that TB patients are negatively impacted by comorbidities such as undernutrition, diabetes mellitus (DM), anemia, or HIV infection [76,77]. ...
Full-text available
Tuberculosis (TB) is a major killer and cause of human suffering worldwide and imposes a substantial reduction in patients’ health-related quality of life (HRQoL). HRQoL indicates the consciousness of patients regarding their physical and mental health. It is, therefore, very relevant in comprehending and measuring the exact impact of the disease state. Therefore, we undertook this review to summarize the available evidence on the impact of TB and its treatment on HRQoL. An in-depth understanding of HRQoL in TB patients can identify the existing management gaps. We undertook a systematic search through PubMed and CENTRAL. Data were extracted and tabulated for study design, targeted population, QoL instrument used, QoL domain assessed, and key findings. We included studies that assessed the effect of TB on the QoL both during and after treatment. There are no specific HRQoL assessment tools for utilization among TB patients. HRQoL is markedly impaired in patients with TB. The factors affecting HRQoL differ with active and latent TB, socio-demographics, socio-economic status, presence of co-infections, etc. This review’s findings can help to frame appropriate policies for tackling HRQoL issues in TB patients.
... showed a lower mortality rate compared to those with lower BMI [13]. By addressing nutrition as an important determinant of pathogenesis and outcome of TB treatment, the health-related quality of life can be improved [14]. The genetic component linked with the pathogenesis of TB is less studied but has been well reported by a study [15]. ...
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The disease burden of tuberculosis (TB) has been declining in the developed world but the goal of eradicating TB seems like a daunting task in the developing regions. Patients with unrecognized TB or those receiving inappropriate treatment pose the greatest risk to the global burden of the disease. The aim of this article is to share the first-hand experience of a doctor, the author, contracting TB and the associated psychological impact. This change in role from a doctor to a patient came as an enlightening experience for the author and would give an insight into the psychological aspect when planning to find effective ways in the fight to eradicate TB.
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Objectives Malnutrition is associated with a twofold higher risk of dying in patients with tuberculosis (TB) and considered an important potentially reversible risk factor for failure of TB treatment. The construct of malnutrition has three domains: intake or uptake of nutrition; body composition and physical and cognitive function. The objectives of this systematic review are to identify malnutrition assessment methods, and to quantify how malnutrition assessment methods capture the international consensus definition for malnutrition, in patients with TB. Design Different assessment methods were identified. We determined the extent of capturing of the three domains of malnutrition, that is, intake or uptake of nutrition, body composition and physical and cognitive function. Results Seventeen malnutrition assessment methods were identified in 69 included studies. In 53/69 (77%) of studies, body mass index was used as the only malnutrition assessment method. Three out of 69 studies (4%) used a method that captured all three domains of malnutrition. Conclusions Our study focused on published articles. Implementation of new criteria takes time, which may take longer than the period covered by this review. Most patients with TB are assessed for only one aspect of the conceptual definition of malnutrition. The use of international consensus criteria is recommended to establish uniform diagnostics and treatment of malnutrition. PROSPERO registration number CRD42019122832.
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Diabetes and undernutrition are common risk factors for TB, associated with poor treatment outcomes and exacerbated by TB. We aimed to assess non-communicable multimorbidity (co-occurrence of two or more medical conditions) in Filipino TB outpatients, focusing on malnutrition and diabetes. In a cross-sectional study, 637 adults (70% male) from clinics in urban Metro Manila (N = 338) and rural Negros Occidental (N = 299) were enrolled. Diabetes was defined as HbA1c of ≥6.5% and/or current diabetes medication. Study-specific HIV screening was conducted. The prevalence of diabetes was 9.2% (54/589, 95%CI: 7.0–11.8%) with 52% newly diagnosed. Moderate/severe undernutrition (body mass index (BMI) <17 kg/²) was 20.5% (130/634, 95%CI: 17.4–23.9%). Forty percent of participants had at least one co-morbidity (diabetes, moderate/severe undernutrition or moderate/severe anaemia (haemoglobin <11 g/dL)). HIV infection (24.4%, 74/303) was not associated with other co-morbidities (but high refusal in rural clinics). Central obesity assessed by waist-to-hip ratio was more strongly associated with diabetes (Adjusted Odds Ratio (AOR) = 6.16, 95%CI: 3.15–12.0) than BMI. Undernutrition was less common in men (AOR = 0.44, 95%CI: 0.28–0.70), and associated with previous history of TB (AOR = 1.97, 95%CI: 1.28–3.04) and recent reduced food intake. The prevalence of multimorbidity was high demonstrating a significant unmet need. HIV was not a risk factor for increased non-communicable multimorbidity.
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Setting The study was conducted at Mulago Hospital, Kampala, Uganda. Objective As chronic respiratory disease (CRD) is a huge, growing burden in Africa, with few available treatments, we aimed to design and evaluate a culturally appropriate pulmonary rehabilitation (PR) program in Uganda for people with post-tuberculosis lung disorder (p-TBLD). Design In a pre–post intervention study, a 6-week, twice-weekly PR program was designed for people with p-TBLD. Outcome measures included recruitment, retention, the Clinical COPD Questionnaire (CCQ), tests of exercise capacity, and biometrics. Given this was a developmental study, no formal statistical significance testing was undertaken. Results In all, 34 participants started PR and 29 (85%) completed all data collection. The mean age of the 29 participants was 45 years, and 52% were female. The mean (95% confidence interval) CCQ score at baseline was 1.8 (1.5, 2.0), at the end of PR was 1.0 (0.8, 1.2), and at 6 weeks after the end of PR was 0.8 (0.7, 1.0). The Incremental Shuttle Walking Test (ISWT) was 299 m (268.5, 329.4) at baseline, 377 (339.6, 413.8) at the end of PR, and 374 (334.2, 413.5) at 6 weeks after the end of PR. Improvements were seen in measures of chest pain; 13/29 (45%) participants reported chest pain at baseline but only 7/29 (24%) at the end of PR, and in those with persistent pain, the mean pain scores decreased. Mild hemoptysis was reported in 4/29 (17%) participants at baseline and in 2/29 (7%) at the end of PR. Conclusion PR for people with p-TBLD in Uganda was feasible and associated with clinically important improvements in quality of life, exercise capacity, and respiratory outcomes. PR uses local resources, requires little investment, and offers a new, sustainable therapy for p-TBLD in resource-limited settings. With the rising global burden of CRD, further studies are needed to assess the value of PR in p-TBLD and other prevalent forms of CRD.
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Background: An understanding of the trends in tuberculosis incidence, prevalence, and mortality is crucial to tracking of the success of tuberculosis control programmes and identification of remaining challenges. We assessed trends in the fatal and non-fatal burden of tuberculosis over the past 25 years for 195 countries and territories. Methods: We analysed 10 691 site-years of vital registration data, 768 site-years of verbal autopsy data, and 361 site-years of mortality surveillance data using the Cause of Death Ensemble model to estimate tuberculosis mortality rates. We analysed all available age-specific and sex-specific data sources, including annual case notifications, prevalence surveys, and estimated cause-specific mortality, to generate internally consistent estimates of incidence, prevalence, and mortality using DisMod-MR 2.1, a Bayesian meta-regression tool. We assessed how observed tuberculosis incidence, prevalence, and mortality differed from expected trends as predicted by the Socio-demographic Index (SDI), a composite indicator based on income per capita, average years of schooling, and total fertility rate. We also estimated tuberculosis mortality and disability-adjusted life-years attributable to the independent effects of risk factors including smoking, alcohol use, and diabetes. Findings: Globally, in 2015, the number of tuberculosis incident cases (including new and relapse cases) was 10·2 million (95% uncertainty interval 9·2 million to 11·5 million), the number of prevalent cases was 10·1 million (9·2 million to 11·1 million), and the number of deaths was 1·3 million (1·1 million to 1·6 million). Among individuals who were HIV negative, the number of incident cases was 8·8 million (8·0 million to 9·9 million), the number of prevalent cases was 8·9 million (8·1 million to 9·7 million), and the number of deaths was 1·1 million (0·9 million to 1·4 million). Annualised rates of change from 2005 to 2015 showed a faster decline in mortality (−4·1% [−5·0 to −3·4]) than in incidence (−1·6% [−1·9 to −1·2]) and prevalence (−0·7% [−1·0 to −0·5]) among HIV-negative individuals. The SDI was inversely associated with HIV-negative mortality rates but did not show a clear gradient for incidence and prevalence. Most of Asia, eastern Europe, and sub-Saharan Africa had higher rates of HIV-negative tuberculosis burden than expected given their SDI. Alcohol use accounted for 11·4% (9·3–13·0) of global tuberculosis deaths among HIV-negative individuals in 2015, diabetes accounted for 10·6% (6·8–14·8), and smoking accounted for 7·8% (3·8–12·0). Interpretation: Despite a concerted global effort to reduce the burden of tuberculosis, it still causes a large disease burden globally. Strengthening of health systems for early detection of tuberculosis and improvement of the quality of tuberculosis care, including prompt and accurate diagnosis, early initiation of treatment, and regular follow-up, are priorities. Countries with higher than expected tuberculosis rates for their level of sociodemographic development should investigate the reasons for lagging behind and take remedial action. Efforts to prevent smoking, alcohol use, and diabetes could also substantially reduce the burden of tuberculosis.
Full-text available
Tuberculosis (TB) is a leading cause of global morbidity, yet there is limited information regarding its impact on quality of life and health status. This is surprising given the implications for patient care, the evaluation of novel treatments or preventative strategies, and also health policy. Furthermore, there is no validated TB-specific instrument that measures health status, and thus a wide and non-standardized range of assessment tools have been employed. The studies to date have chosen a number of different comparator populations, and in many TB endemic areas there is a lack of normative data regarding the health status of the general population. Systematic evaluations of quality of life are urgently needed in specific groups, including those with extrapulmonary TB, drug-resistant disease, HIV co-infection, and latent TB infection, and in children with TB; the assessment of post-treatment disability is also required. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
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Background: There is a dearth of literature on the impact of TB/HIV co-infection on quality of life (QoL). We conducted a study to assess the change in QoL over a 6-months period and its predictors among HIV-infected patients with and without TB in Ethiopia. Methods: 465 HIV-infected patients without TB and 124 TB/HIV co-infected patients were enrolled in a prospective study in February, 2009. 455 (98%) HIV-infected and 97 (78%) TB/HIV co-infected patients were followed for 6 months. Data on QoL at baseline and 6th month were collected by trained nurses through face to face interviews using the short Amharic version of the World Health Organization Quality of Life Instrument for HIV clients (WHOQOL HIV-Brief). Common Mental Disorder (CMD) was assessed using a validated version of the Kessler-10 scale. Multivariate analysis was conducted using generalized estimating equations (GEE) using STATA to assess change in QoL and its predictors. Results: There was a statistically significant improvement of the physical, psychological, social, environmental and spiritual QoL at the 6th months follow up compared to the baseline for both groups of patients (P < 0.0001). The change in QoL in all dimension were more marked for TB/HIV co-infected patients compared to HIV-infected patients without TB.A severe form of CMD was strongly associated with poorer physical QoL among TB/HIV co-infected individuals (β = -2.84; P = 0.000) and HIV clients without TB (β = -2.34; P = 0.000). Conclusion: This study reveals that ART and anti-TB treatment significantly improve the QoL particularly among TB/HIV co-infected patients. We recommend that the ministry of health in collaboration with partners shall integrate mental health services into the TB/HIV programs and train health care providers to timely identify and treat CMD to improve QoL.
Full-text available
Very little is known about the quality of life of tuberculosis (TB) and HIV co-infected patients. In this study in Ethiopia, we compared the quality of life HIV positive patients with and without TB. A cross sectional study was conducted from February to April, 2009 in selected hospitals in Oromiya Regional state, Ethiopia. The study population consisted of 467 HIV patients and 124 TB/HIV co-infected patients. Data on quality of life was collected by trained nurses through face to face interviews using the short Amharic version of the World Health Organization Quality of Life Instrument for HIV clients (WHOQOL HIV). Depression was assessed using a validated version of the Kessler scale. Data was collected by trained nurses and analyzed using SPSS 15.0 statistical software. TB/HIV co-infected patients had a lower quality of life in all domains as compared to HIV infected patients without active TB. Depression, having a source of income and family support were strongly associated with most of the Quality of life domains. In co-infected patients, individuals who had depression were 8.8 times more likely to have poor physical health as compared to individuals who had no depression, OR = 8.8(95%CI: 3.2, 23). Self-stigma was associated with a poor quality of life in the psychological domain. The TB control program should design strategies to improve the quality of life of TB/HIV co-infected patients. Depression and self-stigma should be targeted for intervention to improve the quality of life of patients.
Objective: To determine the prevalence of diabetes mellitus (DM), assess its influence on health-related quality of life (HRQoL) among TB patients. Methods: In this prospective study, eligible patients at three primary health care centers in urban slum region of South Delhi, India, underwent blood glucose screening at treatment initiation. HRQoL scores were determined by conducting face-to-face interviews using Dhingra and Rajpal (DR-12) scale at pretreatment, end of intensive phase and end of the treatment. Results: In 316 patients, the overall DM prevalence was 15.8%, of whom 9.5% were known to have diabetes and 6.3% were diagnosed at TB treatment initiation. DM was more common among patients of older age (p<0.001), with higher BMI (p<0.001), with PTB (p=0.02), and with poor psychological status. HRQoL was significantly poor in the socio-psychological and exercise adaptation domains in DM patients ˃50 years of age at each visit. Older age, poor literacy, loss in workdays, alcohol use and socioeconomic status significantly predict poor HRQoL scores in DM patients. Uncontrolled DM patients demonstrated poor HRQoL at the end of the intensive phase (P=0.04) of treatment and at its completion (P=0.03) compared to those with controlled DM. Conclusion: Addressing screening measures and glycaemic control along with social determinants such as literacy level and alcohol consumption could be an important means of improving the HRQoL of TB with DM patients. This article is protected by copyright. All rights reserved.
Health-related quality of life (HRQOL) among pulmonary tuberculosis (PTB) patients has not been investigated in the Philippines. This study aimed to describe HRQOL among PTB patients and to determine factors that are associated with HRQOL. A cross-sectional survey was conducted at 10 public health centers and 2 non-government organization clinics in District I, Tondo, Manila. Face-to-face interviews using a structured questionnaire including Short Form-8, Duke-UNC Functional Social Support Questionnaire, and Medical Research Council (MRC) dyspnea scale were performed with 561 PTB patients from September to November 2012. HRQOL among PTB patients was generally impaired. Factors associated with lower physical component summary were exposure to secondhand smoke (SHS) (P = 0.038), positive sputum smear result (P = 0.027), not working (P = 0.038), lower education level (P < 0.01), number of symptoms (P < 0.01), number of adverse drug reactions (ADRs) (P < 0.01), higher score on the MRC dyspnea scale (P < 0.01), and low perceived social support (P = 0.027). Lower body mass index (P = 0.016), non-SHS exposure (P = 0.033), number of symptoms (P < 0.01), number of ADRs (P < 0.01), low perceived social support (P < 0.01), and negative perception for waiting time in the clinic (P = 0.026) were identified to be factors significantly associated with lower mental component summary. Socioeconomic status including SHS exposure and low perceived social support, in addition to clinical factors, may be associated with poor HRQOL. Further study would be needed to assess our findings.
Newly diagnosed pulmonary tuberculosis (PTB) patients starting treatment under the Revised National Tuberculosis Control Programme (RNTCP) in a North Indian city. To quantify impairment in health-related quality of life (HRQoL) of PTB patients at the time of diagnosis and during treatment, and to assess the utility of these assessments as a measure of outcome under programme conditions. HRQoL was assessed using the Hindi version of the 26-item World Health Organization Quality of Life (WHOQOL-BREF) scale at the start and end of the intensive phase and at completion of treatment. Four domain scores-physical, psychological, social relationships and environment-were calculated and compared between groups, based on different patient and disease characteristics. Psychometric evaluation was conducted by assessing acceptability, validity and responsiveness of the questionnaire. A total of 2654 HRQoL assessments were performed among 1034 patients. Domain scores were generally better among men, urban residents, younger patients, patients with higher socio-economic status and those with less severe disease. The WHOQOL-BREF demonstrated good psychometric properties, and domain scores improved with treatment. Residual HRQoL impairment was noted in some patients even at treatment completion. HRQoL is impaired in patients with PTB, and improves rapidly and significantly with programme-based treatment. HRQoL assessment can be used as an adjunct outcome measure for patients treated by the RNTCP.