Hazardous Alcohol Drinking and Associated Factors Among Patients With Tuberculosis Attending Public Healthcare Facilities in Gedeo Zone, Southern Ethiopia

doi:10.21203/rs.3.rs-446084/v1

Background: Hazardous drinking is a quantity or pattern of alcohol consumption that places individuals at risk for adverse health events. Studies have shown that hazardous alcohol drinking among patients with tuberculosis has been often linked to a decrease in immune system functioning, greater rates of treatment-resistant cases and death during treatment. However, there are rare studies that assessed the prevalence of hazardous alcohol use and associated factors among patients with tuberculosis in Ethiopia. Therefore, this study was aimed to assess the prevalence of hazardous alcohol drinking and associated factors among patients with tuberculosis attending public healthcare facilities in Gedeo Zone, Southern Ethiopia.

Methods: An institution-based, cross-sectional study was conducted among a randomly selected sample of 415 patients with tuberculosis. The study was conducted at the tuberculosis units of public healthcare facilities in Gedeo zone, Southern Ethiopia. The Alcohol Use Identification Test (AUDIT) scale was used to measure hazardous alcohol drinking. Data on social support, perceived tuberculosis stigma, and depression were collected using a standard, validated, and structured questionnaire.

Results: The prevalence of hazardous alcohol drinking in our study was 20 % (95% CI; 16.1% -24.2%). Medical comorbidity (AOR = 2.44, 95% CI: 1.29–4.62), length of illness (>=12 months) (AOR = 2.88, 95% CI: 1.03–3.04), and being male (AOR = 2.10, 95% CI: 1.17–3.77) were found to be significant predictors of hazardous alcohol drinking after controlling for potential confounders.

Conclusion: A high prevalence of hazardous alcohol drinking was observed among patients with tuberculosis. Therefore, routine screening for alcohol use and a holistic treatment approach for patients with tuberculosis are crucial.

Health Economics & Outcomes Research

Health Policy

Hazardous alcohol drinking

prevalence

associated factors

tuberculosis

Ethiopia

public care units

Alcohol is a psychoactive substance with toxic and dependence producing properties, which is widely used across the world. It is a potent drug that causes both acute and chronic changes in almost all neurochemical systems (1).

The World Health Organization (WHO) defines “hazardous drinking” as “a quantity or pattern of alcohol consumption that places individuals at risk for adverse health events” (2). Hazardous drinking was also defined as an average consumption of 21 drinks or more per week for men (or ≥ 7 drinks per occasion at least 3 times a week), and 14 drinks or more per week for women (or ≥ 5 drinks per occasion at least 3 times a week).” (3).

According to a report from the WHO, globally in 2016, alcohol is the leading cause of premature mortality and disability among those aged 15 to 49 years, accounting for 10% of all deaths in this age group (4). Worldwide in 2016, the harmful use of alcohol resulted in some 3 million deaths worldwide and 132.6 million disability-adjusted life years (DALYs). Mortality resulting from alcohol consumption is higher than that caused by other communicable and non-communicable diseases (5). Harmful use of alcohol is responsible for 5.1% of the global burden of disease (5).

Tuberculosis (TB) is a potentially serious infectious disease that mainly affects the lungs. The bacteria that causes tuberculosis, Mycobacterium TB are spread from one person to another through tiny droplets released into the air via coughs and sneezes (6).

Globally, the best estimate is that 10 million people (range, 9-11.2 million) equivalent to 133 cases (range, 120–148) per 100 000 population developed TB disease in 2017: 5.8 million men, 3.2 million women, and 1.0 million children (7).

Epidemiological data suggest that a significant proportion of patients with tuberculosis had a history of excess alcohol consumption and comorbid alcohol use disorders. A study from the USA revealed that that 15.1% of patients with tuberculosis had reported an excess use of alcohol, with a higher prevalence in males than females (8). Harmful use of alcohol increases the risk of TB threefold and is also a strong risk factor for poor TB treatment adherence (4).

Studies have also shown that alcohol consumption among tuberculosis patients has been often linked to a decrease in immune system functioning, which increases the risk for active tuberculosis (9–11), death during treatment (8) positive smear results (8), higher rates of homelessness (12), and greater rates of treatment-resistant cases (13). Thus, early identification and management of alcohol use problems among patients with tuberculosis are vital to reduce and possibly prevent the associated negative consequences.

However, there are limited studies that assessed the prevalence of hazardous alcohol drinking and the associated factors among patients with tuberculosis. To the best, of our knowledge, there are no previous studies on the prevalence of hazardous alcohol drinking and its associated factors among patients with tuberculosis in Ethiopia. Therefore, this is the first study to determine the prevalence and associated factors of hazardous alcohol drinking among patients with tuberculosis in Ethiopia.

Methods

Study Design and period

Institution-based, cross-sectional study design was used in this study. It was conducted from November 1 to December 30, 2018.

Study setting

The study was conducted among adult patients with tuberculosis attending TB clinic in public health facilities of Yirgacheffe, Wonago, and Dilla Zuriya districts, Gedeo zone, Southern Ethiopia. Gedeo zone is found in South Nation, Nationalities and Peoples’ Regional State of Ethiopia, 359 km southeast of Addis Ababa (the capital city of Ethiopia). In the zone, there are about 42 public healthcare facilities (1 referral hospital, two primary hospitals, and 39 health centers).

Sample size determination and sampling procedure

Since this study was the part of the study on ‘Prevalence of depressive symptoms and associated factors among patients with tuberculosis attending public health institutions in Gede'o zone, South Ethiopia´ the sample size calculated for depression was used for the current study, with the following assumptions of 95% confidence level, a 5% margin of error and a 43.3% prevalence of depression from Ethiopia (14) and a non-response rate of 10% was taken to determine a final sample size of 415. Study participants were proportionally allocated for each health institution, according to patient flow by referring to the previous year annual reports. A systematic sampling technique was used to select the study participants.

Study participants

All patients with TB attending TB clinic were taken as a source population while those patients with TB who were available during the data collection period were considered as a study population. Patients aged 18 and above years old and patients who were on anti-TB medicines for at least 2 weeks were included in the study. Those patients who were severely ill during the study period were excluded.

Data sources and measurement

Data were collected using structured, pretested and standard questionnaire by face-to-face interview technique. Trained nurses and public health professionals working at the TB clinic were collected the data. The questionnaire included socio-demographic data, Patient Health Questionnaire-9 (PHQ-9), Oslo social support Scale-3 and structured questions for assessment of the associated factors.

The dependent variable hazardous alcohol drinking was measured as a dichotomous variable (Yes/No) on 10 items of the AUDIT, with the cutoff point set at greater than or equal to 8, that is, patients with tuberculosis who scored greater than 8 had hazardous alcohol drinking.

The 10-item Alcohol Disorder Identification Test (AUDIT) assesses alcohol consumption level, symptoms of alcohol dependence and problems associated with alcohol use. Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; a score of 8 and above indicates a tendency to problematic drinking or hazardous or harmful drinking. AUDIT was translated into Amharic and back to English by two different language expertise and mental health professionals for checking its consistency (15–17).

Data quality management

The questionnaire was designed in English and was translated to Amharic and back to English, that is, forward and backward translation. The questionnaire was designed and modified appropriately to control the quality of the data. The questionnaire was pretested on 5% of the sample. The data collection process was supervised on a daily basis by the supervisors and principal investigator, and the completed questionnaires were checked for completeness and coded.

Statistical Analysis

Data was entered using Epi-Data version 3.1 and analyzed using SPSS-20. Means, frequencies, and percentages were used to summarize the data, which was then presented in the form of figures, tables, and text. The strength of the association was presented by crude odds and adjusted odds ratio with their corresponding 95% CI. Statistical significance was set at p < 0.05.

Study Design and period

Institution-based, cross-sectional study design was used in this study. It was conducted from November 1 to December 30, 2018.

Study setting

The study was conducted among adult patients with tuberculosis attending TB clinic in public health facilities of Yirgacheffe, Wonago, and Dilla Zuriya districts, Gedeo zone, Southern Ethiopia. Gedeo zone is found in South Nation, Nationalities and Peoples’ Regional State of Ethiopia, 359 km southeast of Addis Ababa (the capital city of Ethiopia). In the zone, there are about 42 public healthcare facilities (1 referral hospital, two primary hospitals, and 39 health centers).

Sample size determination and sampling procedure

Since this study was the part of the study on ‘Prevalence of depressive symptoms and associated factors among patients with tuberculosis attending public health institutions in Gede'o zone, South Ethiopia´ the sample size calculated for depression was used for the current study, with the following assumptions of 95% confidence level, a 5% margin of error and a 43.3% prevalence of depression from Ethiopia (14) and a non-response rate of 10% was taken to determine a final sample size of 415. Study participants were proportionally allocated for each health institution, according to patient flow by referring to the previous year annual reports. A systematic sampling technique was used to select the study participants.

Study participants

All patients with TB attending TB clinic were taken as a source population while those patients with TB who were available during the data collection period were considered as a study population. Patients aged 18 and above years old and patients who were on anti-TB medicines for at least 2 weeks were included in the study. Those patients who were severely ill during the study period were excluded.

Data sources and measurement

Data were collected using structured, pretested and standard questionnaire by face-to-face interview technique. Trained nurses and public health professionals working at the TB clinic were collected the data. The questionnaire included socio-demographic data, Patient Health Questionnaire-9 (PHQ-9), Oslo social support Scale-3 and structured questions for assessment of the associated factors.

The dependent variable hazardous alcohol drinking was measured as a dichotomous variable (Yes/No) on 10 items of the AUDIT, with the cutoff point set at greater than or equal to 8, that is, patients with tuberculosis who scored greater than 8 had hazardous alcohol drinking.

The 10-item Alcohol Disorder Identification Test (AUDIT) assesses alcohol consumption level, symptoms of alcohol dependence and problems associated with alcohol use. Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; a score of 8 and above indicates a tendency to problematic drinking or hazardous or harmful drinking. AUDIT was translated into Amharic and back to English by two different language expertise and mental health professionals for checking its consistency (15-17).

Data quality management

The questionnaire was designed in English and was translated to Amharic and back to English, that is, forward and backward translation. The questionnaire was designed and modified appropriately to control the quality of the data. The questionnaire was pretested on 5% of the sample. The data collection process was supervised on a daily basis by the supervisors and principal investigator, and the completed questionnaires were checked for completeness and coded.

Statistical Analysis

Data was entered using Epi-Data version 3.1 and analyzed using SPSS-20. Means, frequencies, and percentages were used to summarize the data, which was then presented in the form of figures, tables, and text. The strength of the association was presented by crude odds and adjusted odds ratio with their corresponding 95% CI. Statistical significance was set at p<0.05.

Socio-demographic and economic characteristics

A total of 409 participants were interviewed, of whom 252 (61.6%) were males. More than fifty percent of the participants resided in rural areas. Of the participants, 66.5 % were engaged in government works and private business. One-third of the participants were aged below

24 years and more than 50 % were married. Regarding literacy, 22.5% had not attended formal education, 40.3 % primary education, more than one-third 37.2 % had secondary and above education. The majority of the participants had a monthly income of <1539 and 21.8 % had >= 1539 ETB per month (Table 1).

Psychosocial and Clinical characteristics of the respondents

One-third of the participants with harmful alcohol use 139 (34 %) had poor social support, 177 (43.1%) had intermediate social support. Regarding perceived TB stigma, more than one-third of the participants (159 (38.9%) had perceived TB stigma, and a greater proportion (61.6 %, n = 250) of participants had not perceived TB related stigma.

A greater proportion (73.8 %, n = 302) of participants were pulmonary TB patients, and (61.6 %, n = 250) of the participants were in the intensive phase of the treatment (the first two months of treatment).

A large proportion of the participants (77 %, n = 315) were medium adherent to TB treatment. Majority of the participants were new TB patients and 15.2 % were re-treatment cases.

In addition to TB, 71 (17.4%) had HIV, and 22 participants reported having other co-morbid chronic illnesses: hypertension (n = 6), cardiac illness (n = 10), diabetes mellitus (n = 2), and kidney disease (n = 4). Only 5.1% had a family history of mental illness. Two hundred thirty-six (57.7 %) were interviewed within 6–12 months of their illness. Nearly half of the participants had depressive symptoms (Table 2).

Prevalence of hazardous alcohol drinking

The 10-items of the Alcohol Disorder Identification Test (AUDIT) were summed and single variable was generated (18). A score of 8 and above indicates a tendency to hazardous alcohol drinking. A total of 82 (20%) patients with tuberculosis were hazardous alcohol drinkers.

Factors associated with hazardous alcohol drinking

Socio-demographic factors, clinical factors, and psychosocial factors were used to identify statistically significant factors. Among all covariates, age, gender, marital status, having depression, medical comorbidity, duration of illness, social support and category of TB treatment were found to have p-value less than 0.2 from bi-variable logistic regression and considered for the multiple logistic regression model. The model goodness of fit was tested using Hosmer and Lemeshow test and the p-value was found to be 0.64, which revealed as the model is good.

The odds of hazardous alcohol drinking increased by 2.10 times (95% CI: 1.17, 3.77) for male than females. Not having medical comorbidity has reduced risk of hazardous alcohol drinking. Those TB patients who had the comorbid medical conditions were about more than two times (AOR = 2.44, 95 % CI: 1.29–4.62) more at risk of hazardous alcohol drinking than patients who had no medical comorbidity.

The duration of illness was associated with hazardous alcohol drinking among TB patients. The odds of hazardous alcohol drinking increased by 2.88 times (95 % CI: 1.03–3.04) for patients who had a longer duration of illness as compared to patients who had shorter period of illness (<6 months) (Table 3).

The prevalence of hazardous alcohol drinking among patients with tuberculosis in the current study was found to be 20% (95 % CI = 16.1–24.2). The current estimate is lower than the studies conducted in Botswana, Lesotho, India and Thailand (24.7%, 35.1%, 29% 32% and 24.4% (10, 19-22). This might be because of difference in study setting, study deign, study year, socio-demographic and type of screening tool used.

Even though all studies from Botswana, South India and Lesotho used AUDIT that might make it similar with the current study, the population, year of study and the socio-demographic difference might account for the difference. The estimate of the current study is consistent with studies reported from South Africa, Scotland and USA (23.3%, 23.2%, 18% and 17.9% respectively (23-26).

On the other hand, the estimate of the current study is by far higher than one study conducted in USA (15.1%) (27). The tool used for measuring hazardous alcohol drinking, and the cutoff point used to categorize the patients' alcohol use behavior is completely different from the current study. On top of that, the study design, study time and setting at which the current data was collected could be considered as a source of variation in estimation between the current and compared study.

The current study also identified different factors that had an association with hazardous alcohol drinking among patients with TB. Sex of the participant was one of the factors that had a significant association with hazardous alcohol drinking. The risk of hazardous alcohol drinking for men participants was higher as compared to women. This might be due to the biological differences in reactions to alcohol use, and that gender differences in alcohol use behavior may be modified by psychosocial and cultural factors (5, 28-30). The study result is consistent with an institution based cross-sectional studies from Namibia, Lesotho, India and, Scotland (19, 22, 25, 31).

The other factor that had a significant association with hazardous alcohol drinking was the duration of illness. The odd of hazardous alcohol drinking was 2.88 times higher among those who had longer duration of illness as compared to those who had less than 6 months of illness duration. A systematic review conducted on the association between alcohol use, alcohol use disorders and tuberculosis reported a risk of alcohol use for TB treatment outcome and vice versa (32).

Alcohol use has a negative impact on the clinical course of TB (33, 34). People drinking alcohol show higher relapse rates, a higher probability of poor clinical outcome, and a higher probability of experiencing Multi-Drug Resistant-TB (35-37).

The other factor, which increased the odd of hazardous alcohol drinking was medical comorbidity, HIV/AIDS and other chronic disease. Those who had comorbid medical conditions were 2.44 times at higher risk of being hazardous alcohol user as compared to patients without medical comorbidity (30). So far, the current finding is supported by WHO, global status report on alcohol and health 2018 (5). This might be because of the fact that having medical comorbidity will increase stress and other psychological problems.

Unlike other studies, the current study did not find any association between hazardous alcohol drinking, and; age of the participant, marital status, depressive symptoms, social support and category of TB treatment.

The strengths and limitations of the study

Our study has two major strengths. First, the study assessed hazardous alcohol drinking, which was not previously studied. Second, validated and standardized tools were used to assess hazardous alcohol drinking and independent variables.

Since the cross-sectional study design could not establish clear risks of hazardous alcohol drinking among patients with tuberculosis, it was difficult to imply the temporal relationship between significantly associated factors and hazardous alcohol drinking. In addition to this, the authors did not consider other mental health issues that can confound study outcome. For instance, the presence of severe mental illness and tobacco use, which are commonly associated with alcohol use. Therefore, we recommend further studies to focus on tobacco use and comorbid severe mental health disorders.

In this study, we found that a substantial percentage of patients with tuberculosis were hazardous alcohol drinkers (20%). Having medical comorbidity, a longer duration of illness (12 months and above), being male were found to be significant predictors of hazardous alcohol drinking. Therefore, routine screening and a holistic treatment approach of alcohol use among patients with tuberculosis are crucial.

AUDIT: Alcohol Use Disorders Identification Test

DALYs: Disability Adjusted Life Years

PHQ-9: nine-item Patient Health Questionnaire

TB: Tuberculosis

Competing interests: The authors declare that they have no competing interests.

Authors’ contributions: KY and HM conceived the topic and participated in the data collection, data analysis and writing of the paper. HM, GA, KK and HM contributed to the drafting and critical review of the paper. KY and GA wrote the manuscript. All authors read and approved the final manuscript.

Acknowledgements: The researchers acknowledge the entire staff of the Gedeo zone public health institutions for their cooperation in giving information. Our sincere gratitude goes to Dilla University, College of Medicine and Health Sciences, Research and Dissemination Office for funding the study. All the authors of the paper would like to acknowledge Dilla University, Research Director Office for their support. We also appreciate data collectors, study participants and Gedeo zone health department.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethical approval was obtained from Institutional Review Board (IRB) of Dilla University, college of health science and medicine. Permission letter from zonal health department was also secured before data collection. Necessary permission was obtained from the health offices of respective districts (i.e. Yirgacheffe district, Wonago district, and Dilla Zuriya district), and the health centers. The patients’ confidentiality was respected, where only codes were used instead of the patients’ name.

Funding: This research work was funded by Dilla University.

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Table 1 Distribution of patients with tuberculosis attending the tuberculosis unit of public healthcare facilities, Gedeo zone, South Ethiopia, 2018 (n = 409)

Variables	Categories	Frequency	Percent (%)
Sex	Male	252	61.6
Sex	Female	157	38.4
Age in years	18-24	135	33
	29-34	122	29.8
	35-44	85	20.8
	45 and above	67	16.4
Marital status	Married	217	53.1
	Single	157	38.3
	Divorced/Single/divorced	35	8.6
Level of education	No formal education	92	22.5
	Primary education	165	40.3
	Secondary education	152	37.2
Occupational status	Employed	272	66.5
Occupational status	Unemployed	137	33.5
Place of residence	Rural	217	53.1
Place of residence	Urban	192	46.9

Table 2 Description of Psychosocial and Clinical characteristics of patients with tuberculosis attending the tuberculosis unit of public healthcare facilities, Gedeo zone, South Ethiopia, 2018 (n = 409)

Variables	Categories	Number (%)
Perceived TB stigma	No	132 (32.3)
Perceived TB stigma	Yes	277 (67.7)
Adherence to TB medication	High adherence	41 (10.0)
	Medium adherence	315 (77.0)
	Low adherence	53 (13.0)
Perceived social support	Poor social support	139 (34.0)
	Intermediate social support	177 (43.1)
	Strong social support	93 (22.9)
Classification of TB	Pulmonary	302 (73.8)
Classification of TB	Extra-pulmonary	107 (26.2)
Phase of treatment	Intensive phase	250 (61.1)
Phase of treatment	Continuation phase	159 (38.9)
Treatment category	New case	347 (84.8)
Treatment category	Re-treatment case	62 (15.2)
Comorbidity	TB/HIV comorbidity	71 (17.4)
	Other comorbid condition	22 (5.4)
	No comorbidity	316 (77.2)
Depressive symptoms	No	223 (54.5)
Depressive symptoms	Yes	186 (45.5)

Table 3 Bivariate and multivariable analysis of factors associated with hazardous alcohol drinking among patients with tuberculosis attending tuberculosis unit of healthcare facilities, Gedeo zone, South Ethiopia, 2018 (n = 409)

VARIABLES	CATEGORIES	Hazardous alcohol drinking		COR (95%CI)	AOR (95% CI)
VARIABLES	CATEGORIES	Yes	No	COR (95%CI)	AOR (95% CI)
Sex of the participants	Male	57	195	1.54 (0.91, 2.59)	2.10 (1.17, 3.77) *
Sex of the participants	Female	25	132	1	1
Marital status	Married	46	171	1	1
	Single	24	133	0.67 (0.39, 1.15)	1.04 (0.54, 2.03)
	Widow/ Divorced/ Separated	12	23	1.94 (0.89, 4.18)	0.87 (0.34,2.21)
Age of participants	18- 24 years	13	122	0.34 (0.15, 0.75)	0.38 (0.14, 1.01)
	25-34 years	27	95	0.90 (0.44, 1.83)	0.83 (0.37,1.88)
	35-44 years	26	59	1.40 (0.67, 2.90)	1.17 (0.52, 2.64)
	45 years and above	16	51	1	1
Depression	Yes	55	131	3.04 (1.82, 5.08)	1.54 (0.84, 2.83)
Depression	No	27	196	1	1
Medical Comorbidity	Yes	34	59	3.21 (1.90, 5.42)	2.44 (1.29, 4.62) **
Medical Comorbidity	No	48	268	1	1
Duration of illness	< 6 months	6	72	1	1
	6 -12 months	47	189	2.98 (1.22, 7.29)	2.47 (0.96, 6.35)
	>=12 months	29	66	5.27 (2.05, 13.5)	2.88 (1.03, 8.04) *
Social support	Poor social support	42	97	2.49 (1.52, 4.07)	1.36 (0.75, 2.48)
Social support	Good social support	40	230	1	1
Category of TB treatment	New case	58	289	1	1
Category of TB treatment	Re-treatment case	24	38	3.14 (1.75, 5.64)	1.66 (0.80, 3.43)

Key: * = p-value less than 0.05; COR crude odds ratio, AOR adjusted odds ratio, CI confidence interval

Hazardous Alcohol Drinking and Associated Factors Among Patients With Tuberculosis Attending Public Healthcare Facilities in Gedeo Zone, Southern Ethiopia

Status:

Version 1

Abstract

Background

Methods

Study Design and period

Study setting

Sample size determination and sampling procedure

Study participants

Data sources and measurement

Data quality management

Statistical Analysis

Methods

Results

Discussion

Conclusion And Recommendation

Abbreviations

Declarations

References

Tables

Status:

Version 1