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Evaluation of a community based out-patient treatment program for tubercular patients resident in downtown… Ostry, Aleck Samuel 1986

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EVALUATION  OF A COMMUNITY BASED  OUT-PATIENT  TREATMENT PROGRAM FOR TUBERCULAR PATIENTS  RESIDENT  IN DOWNTOWN DISTRICTS OF VANCOUVER By ALECK SAMUEL OSTRY B.Sc,  The U n i v e r s i t y  A THESIS SUBMITTED  of B r i t i s h Columbia,  1976.  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (HEALTH SERVICES PLANNING AND  ADMINISTRATION)  in THE FACULTY OF GRADUATE STUDIES ( D e p a r t m e n t o f H e a l t h C a r e and E p i d e m i o l o g y )  We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA May, (c)Aleck  1986  Samuel O s t r y , 1986  In p r e s e n t i n g t h i s t h e s i s requirements  i n p a r t i a l f u l f i l m e n t of  f o r an a d v a n c e d d e g r e e a t  the  the  University  of  B r i t i s h Columbia, I agree that  t h e L i b r a r y s h a l l make  it  freely available  and s t u d y .  for reference  agree t h a t p e r m i s s i o n f o r e x t e n s i v e for  s c h o l a r l y purposes  for  financial  copying or p u b l i c a t i o n of t h i s  HEALTH  CARE  AND  The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  7Q ^  It  is thesis  g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n  Department of  APRIL  thesis  may be g r a n t e d by t h e h e a d o f my  permission.  Date  further  copying of t h i s  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . understood that  I  23 r d /1986.  EPIDEMIOLOGY.  i i ABSTRACT T h i s s t u d y i s an e v a l u a t i o n of  ( i n terms of a t t e n d a n c e  compliance)  t h e community b a s e d t u b e r c u l o s i s o u t - p a t i e n t p r o g r a m  Downtown Community H e a l t h C l i n i c  (DCHC) i n V a n c o u v e r .  c o m p l i a n c e i s a measure o f t h e d e g r e e o f a d h e r e n c e regime  Treatment  t o a treatment  e s t a b l i s h e d by c a r e g i v e r s whereas a t t e n d a n c e  i s concerned only with attendance t o c l i n i c  at the  compliance  appointments.  Because  t r e a t m e n t a t t h e DCHC i s s u p e r v i s e d , a t t e n d a n c e c o m p l i a n c e c a n be closely The  associated with treatment compliance. DCHC was e s t a b l i s h e d  trict  i n 1980 i n an e f f o r t  skid-row  population.  i n Vancouver's  downtown a r e a .  Prior  therapy  at  Prior  to  1980, s k i d - r o w  to  t h e WCC l a s t e d  is  1979, h o s p i t a l - b a s e d  18-24 months a n d  was  a  were  outside  out-patient unsupervised.  lasts  9  months.  s u p e r v i s e d by a t u b e r c u l o s i s n u r s e a t t h e DCHC who  p l a y s a key r o l e on  patients  (WCC), l o c a t e d  C o m m u n i t y - b a s e d t r e a t m e n t a t t h e DCHC g e n e r a l l y Treatment  dis-  t o r e d u c e t u b e r c u l o s i s r a t e s among t h e  r e q u i r e d t o a t t e n d t h e W i l l o w Chest C l i n i c the  Downtown-Eastside  i n p r o m o t i n g c o m p l i a n c e . The e v a l u a t i o n  comparison  of attendance t o appointments  at  i s based  both  these  clinics. As  background  epidemiology particular  a model  i n developed countries i n general i sdescribed.  r a t e s have f a l l e n , h a v e emerged;  f o r the evaluation,  of and  The model shows t h a t a s  t h r e e main g r o u p s a t h i g h - r i s k  a b o r i g i n a l people,  tuberculosis Canada  in  tuberculosis  for thedisease  i m m i g r a n t s from c o u n t r i e s  with  h i g h r a t e s , and non-Native r e s i d e n t s of urban skid-row d i s t r i c t s . These  t h r e e groups a r e w e l l r e p r e s e n t e d i n Vancouver's  skid-row  iii districts  and account  f o r most o f t h e p a t i e n t  population  at the  DCHC. The  s t u d y o u t l i n e s how t u b e r c u l o s i s  evolved  in  relation  to  technological  changing epidemiology of t u b e r c u l o s i s adaptation Vancouver based  out-patient  patient The  o f modern t u b e r c u l o s i s i s traced,  culminating  The w e l l  with  known a s s o c i a t i o n  between t u b e r c u l o s i s  Worlds F a i r a r e described  period  interaction  alienated  particular  major  out-  i s  tubercular  their  possible  outlined.  their treaton  must t a k e d r u g s r e g u l a r l y f o r a  requires  a lengthy  population  and d i s c i p l i n e d  on s k i d - r o w ,  Attendance  to c l i n i c  poor and  t h i s may p o s e  appointments important  in  factor  outcome.  p i v o t a l r o l e of attendance  socio-demographic  of the  f o ra discussion  d r u g s may be t h e s i n g l e most treatment  of t h e  related to  t h e socio-demography  the stage  then  and poverty  t h e treatment system. For the g e n e r a l l y  to receive  the  This  difficulties.  a successful With  sets  Tubercular patients of time.  and  a n d shows t h e r a t i o n a l e b e h i n d  ( a t t h e DCHC),  with  problem  which o u t l i n e s  population  compliance.  in  and  t h e development of h o s p i t a l  Socio-demographic upheavals i n the area 1986  system  order  B.C.  epidemiology of Vancouver's skid-row  background,  tubercular  often  i n d e v e l o p e d c o u n t r i e s . The  t r e a t m e n t methods i n  e f f e c t s on t h e s k i d - r o w t u b e r c u l o s i s  long  and t h e  i n r e l a t i o n t o the socio-demographic conditions  Vancouver's  ment  developments  have  t r e a t m e n t a t t h e WCC a n d c o m m u n i t y b a s e d  tuberculosis  is discussed.  This  strategies  t r e a t m e n t a t t h e DCHC.  described area.  treatment  factors  compliance  predictive  for  established, attendance  iv compliance by  a t t h e DCHC a r e d e t e r m i n e d a n d t h e DCHC i s e v a l u a t e d  comparing i t ' s a b i l i t y  the  WCC.  the  evaluation  t o promote a t t e n d a n c e c o m p l i a n c e  A r e t r o s p e c t i v e case c o n t r o l study d e s i g n i s used c o m p a r i n g t h e DCHC c l i e n t s  for the years  w i t h m a t c h e d c o n t r o l s who a t t e n d e d t h e WCC i n t h e y e a r s Results patients  of  the evaluation  i n d i c a t e attendance  a t t h e DCHC was s i g n i f i c a n t l y  Furthermore,  four  better  1977-79.  i d e n t i f i e d . These were, i n o r d e r o f i m p o r t a n c e , p a t i e n t ' s relation t o the c l i n i c ,  and  race.  p a t i e n t ' s age,  of  t h e WCC.  major f a c t o r s p r e d i c t i v e f o r compliance  in  in  1981-83  compliance  than a t  with  were  address  s e v e r i t y of d i a g n o s i s  V  TABLE OF CONTENTS PAGE i i  ABSTRACT TABLE OF CONTENTS  v  L I S T OF TABLES  v i i  L I S T OF FIGURES  ix  ACKNOWLEDGEMENTS CHAPTER  1  CHAPTER 2  CHAPTER 3  CHAPTER 4  CHAPTER 5  CHAPTER 6  x INTRODUCTION 1 .1 O v e r v i e w 1.2 The Q u e s t i o n s 1.3 T h e s i s S t r u c t u r e  1 3 4  TUBERCULOSIS EPIDEMIOLOGY 2.1 T u b e r c u l o s i s P a t h o g e n e s i s 6 2.2 E p i d e m i o l o g y i n D e v e l o p e d N a t i o n s . . . 7 2.3 The C o h o r t E f f e c t 10 THE EVOLUTION o f TUBERCULOSIS TREATMENT 3.1 I n t r o d u c t i o n 13 3.2 P r e - M o d e r n E r a o f T.B. T r e a t m e n t . . . 13 3.3 Modern E r a o f T.B. T r e a t m e n t 14 1 . S u r g i c a l Treatment 14 2.Sanitoria 15 3 . Chemotherapy 17 4.1 4.2 4.3 4.4  TUBERCULOSIS CONTROL IN B.C. The E a r l y Y e a r s The D i v i s i o n o f T.B. C o n t r o l The W i l l o w C h e s t C l i n i c The Downtown Community C l i n i c  25 .25 28 29  EPIDEMIOLOGY and SOC IO-DEMOGRAPHY i n t h e STUDY AREA 5.1 I n t r o d u c t i o n 32 5.2 T . B . E p i d e m i o l o g y i n t h e S t u d y A r e a . 3 2 5.3 S o c i o - d e m o g r a p h y o f t h e S t u d y A r e a . 3 8 5.4 The H i g h R i s k G r o u p s 42 COMPLIANCE 6.1 C o m p l i a n c e and S o c i o - d e m o g r a p h y . . . . 4 8 6.2 A t t e n d a n c e C o m p l i a n c e 50  vi TABLE OF CONTENTS CHAPTER 7  (cont'd)  THE EFFECT OF TWO TYPES OF C L I N I C SYSTEMS ON COMPLIANCE TO T.B. CHEMOTHERAPY. METHODS:  PAGE 7 . 1 Overview 53 7.2 The Sample 1. Sample S e l e c t i o n 54 2. Sample B o u n d a r i e s 55 7.3 The V a r i a b l e s 56 1. I n d e p e n d e n t V a r i a b l e s 56 2. I n t e r v e n i n g V a r i a b l e s 57 3. Dependent V a r i a b l e s 57 7.4 C o d i n g 58 7.5 B i a s 61 7.6 S t u d y D e s i g n 1 . Question 1 62 A) P o p u l a t i o n . a n d S e t t i n g . . . 6 2 B) M a t c h i n g 63 2. Q u e s t i o n 2 64 3. Q u e s t i o n 3 65 4. S e c t i o n 4 ' D r o p - o u t s ' 65  CHAPTER  CHAPTER  8.  THE  9  EFFECTS OF TWO TYPES OF C L I N I C SYSTEMS ON COMPLIANCE TO T.B. CHEMOTHERAPY. RESULTS AND DISCUSSION:  8. 1 Q u e s t i o n 1 8.2 Q u e s t i o n 2 8.3 Q u e s t i o n 3  67 71 76  8.4  82  'Drop-outs'  CONCLUSIONS AND  RECOMMENDATIONS  84  REFERENCES  88  APPENDICES  92  Appendix  A  Map  o f N o r t h H e a l t h U n i t and S t u d y  Appendix  B  Map  of Recoded Areas  Area....93 94  vii L I S T OF TABLES PAGE 18  Table I :  T.B. D e a t h R a t e  i n B.C. a n d Canada  Table I I :  Sanatoria Population  Table I I I :  P e r c e n t a g e o f T.B. O u t - p a t i e n t s a t t h e WCC  i n B.C. ( 1 9 5 2 - 6 4 )  26 ..28  Table IV: C o m p a r i s o n o f I n c i d e n c e R a t e s i n B.C., M e t r o Vancouver, t h e N o r t h H e a l t h U n i t , t h e Study A r e a and C e n s u s T r a c t 58 d u r i n g t h e S t u d y P e r i o d 32 T a b l e V: C o m p a r i s o n o f t h e Mean R a t e s i n B.C., M e t r o Vancouver, t h e North H e a l t h U n i t , t h e Study Area and C e n s u s T r a c t 58 d u r i n g t h e S t u d y P e r i o d  33  Table V I : Percentage of Canadian-born and non-Canadianb o r n P e r s o n s i n t h e S t u d y A r e a a n d C e n s u s T r a c t 58 D u r i n g the Study P e r i o d 35 Table V I I : P e r c e n t a g e of N a t i v e and n o n - N a t i v e Canadianb o r n C a s e s i n t h e S t u d y A r e a a n d C e n s u s T r a c t 58 D u r i n g the Study P e r i o d 36 T a b l e VI11:Socio-demographic D i s t r i b u t i o n of Study Area T.B. C a s e s R e g i s t e r e d i n t h e Y e a r s 1977-79 & 1 9 8 1 - 8 3  45  T a b l e I X : S o c i o - d e m o g r a p h i c C h a r a c t e r i s t i c s o f WCC a n d DCHC P a t i e n t s f o r t h e P e r i o d 1981-83  48  T a b l e X: T r e a t m e n t S t a t u s o f T.B. C a s e s D u r i n g t h e Study P e r i o d Table X I :  i n t h e Study  W i l c o x o n S i g n e d Rank T e s t f o r M a t c h e d  Area 55  Data....67  T a b l e X I I : Mean Ages i n t h e C o n t r o l , E x p e r i m e n t a l a n d Unmatched G r o u p s by Race T a b l e X I I I : T o t a l Treatment C a s e s a t t h e WCC a n d DCHC  Length f o r Matched  68  Hospitalized 69  T a b l e XIV: Comparison o f Compliance and O u t - p a t i e n t Treatment Length between H o s p i t a l i z e d and N o n - h o s p i t a l i z e d P a t i e n t s a t t h e DCHC a n d WCC 70 T a b l e XV: On^vray A n a l y s i s o f V a r i a n c e f o r I n d e p e n d e n t Variables  72  Table XVI: M u l t i p l e C l a s s i f i c a t i o n Analysis Major Independent V a r i a b l e s  73  (MCA) f o r  viii L I S T OF TABLES  (cont'd)  T a b l e XVII:MCA T a b l e S h o w i n g D e v i a t i o n s f r o m Mean T a b l e XVIII:Mean Table XIX: Quartiles  Compliance  Compliance  PAGE  by Recoded Age C a t e g o r y  C r o s s t a b u l a t i o n o f Age C a t e g o r y  by  Compliance  74 75 77  T a b l e X X : C r o s s t a b u l a t i o n o f A r e a by C o m p l i a n c e Q u a r t i l e s . 7 7 T a b l e X X I : 2-Way ANOVA by  Age a n d A r e a f o r  T a b l e X X I I : C r o s s t a b u l a t i o n o f Race by Quartiles  Compliance...78  Compliance  79  T a b l e X X I I I : C r o s s t a b u l a t i o n o f H o s p i t a l i z a t i o n by Race...79 T a b l e XXIV: C r o s s t a b u l a t i o n o f D i a g n o s i s by Quartiles  Compliance  80  T a b l e X X V : C r o s s t a b u l a t i o n o f H o s p i t a l i z a t i o n by Quartiles  Compliance 80  T a b l e XXVI : C r o s s t a b u l a t i o n o f Race by D i a g n o s i s  81  ix L I S T OF FIGURES FIGURE 1  G e n e r a l Model of T u b e r c u l o s i s  FIGURE 2  Becker's Health  B e l i e f Model  PAGE Epidemiology..8 50  X  ACKNOWLEDGEMENTS I  want  people this  t o acknowledge the c o o p e r a t i o n and  of  o r g a n i z a t i o n s i n t h e p r e p a r a t i o n and d e v e l o p m e n t  thesis.  Division  h e l p and s u p p o r t  I  am g r a t e f u l t o t h e M i n i s t r y o f H e a l t h  of T u b e r c u l o s i s C o n t r o l f o r g i v i n g t h e i r  t h i s study.  In t h i s regard  I would p a r t i c u l a r l y  and  approval  like  key of the for  t o thank the  D i r e c t o r o f T.B. C o n t r o l , D r . E. A l l e n . E v e r y o n e a t t h e D i v i s i o n o f T.B. quick  C o n t r o l was v e r y  t o p r o v i d e a s s i s t a n c e and i n f o r m a t i o n . I w o u l d  h e l p f u l and particularly  l i k e t o t h a n k D r . C. Chao and Ms. P. L e n t i t h e T.B. n u r s e o n - s i t e a t t h e Downtown Community Last,  but  not  least,  Clinic. I want t o t h a n k  my  thesis  committee  c o n s i s t i n g o f D r . D. E n a r s o n , D r . R. M a t h i a s and D r . N. My me,  c o m m i t t e e was e f f i c i e n t and s u p p o r t i v e . I l e a r n e d a l o t and d e v e l o p e d new s k i l l s  tutelage. for  her  Finally,  beyond the c a l l  of  Most i m p o r t a n t l y f o r from t h e i r  I want t o g i v e s p e c i a l t h a n k s t o D r .  perceptive  t e a c h i n g and s u s t a i n e d  duty.  Morrison.  support  effective Morrison  which  went  CHAPTER  1.  INTRODUCTION 1.1  OVERVIEW:  Over  the  past  tuberculosis  in  Tuberculosis, countries, often  fifty  developed  once  has  years  a  been  the prevalence  c o u n t r i e s has  wide-spread limited  and  incidence  contained  and  in  prevalence  disease  Although  developed rates  of  immigrants marginal  the  groups  from  most a t r i s k  countries with high  o f t e n a l c o h o l i c men l i v i n g  In Canada,  in  industrialized  high-risk  countries,  can  reach  in  of  drastically.  the disease  d e v e l o p i n g c o u n t r i e s among t h e s e h i g h - r i s k Some  incidence  declined  to well defined  l o c a t e d i n urban c e n t r e s .  localized  and  groups  has  been  tuberculosis  levels  found  in  groups. developed  T.B.  nations  rates  and  in"skid-row" areas  t h e r e i s a t h i r d h i g h - r i s k group,  are  socially of c i t i e s .  that i s aboriginal  peoples. In  Vancouver,  a l l three  high-risk  groups  are  present.  M o r e o v e r , i n t h e Downtown C o r e , D o w n t o w n - E a s t s i d e and S t r a t h c o n a * d i s t r i c t s which a r e contiguous parts is  w i t h c e n s u s t r a c t s 57,  of these communities o v e r l a p and c o - e x i s t .  among  the  poorest  i n Vancouver  and  highest A  of t h e C i t y H e a l t h Department, 43 i n c i d e n c e o f t u b e r c u l o s i s i n B.C."  mass s c r e e n i n g p r o g r a m i n t h e S t u d y A r e a  Spring problem  of  1985  underscored  i n the area.  were d e t e c t e d a f t e r  Eight  screening  *From now on t h i s a r e a  to  Dr.  " T h i s a r e a has  59 Area J. the  c a r r i e d out i n the  the magnitude of new-active  The S t u d y  according  Blatherwick  58 a n d  cases  the t u b e r c u l o s i s of  tuberculosis 22  1276 Downtown r e s i d e n t s . T h i s means  i s r e f e r r e d t o a s t h e 'Study 1  Area'.  the  prevalence rate  hundred  among t h e s c r e e n e d p o p u l a t i o n  r e s t o f B.C. t h e h i g h studied  attempt  tuberculosis  i n Vancouver and t h e t u b e r c u l o s i s e p i d e m i o l o g y of t h e  to  unexplored.  contribute  1980, i n an e f f o r t  This  understanding  t u b e r c u l o s i s among t h i s h i g h  risk  thesis i spartially  to  the epidemiology  rates  e s t a b l i s h e d a community b a s e d  1980, s k i d  based  Tuberculosis  tuberculosis  row t u b e r c u l o s i s p a t i e n t s a t t e n d e d a  Hospital  out-patient  Clinic.  t r e a t m e n t program a t t h e W i l l o w Chest C e n t r e a t  General  of  specifically  t h e B.C. D i v i s i o n o f  t r e a t m e n t p r o g r a m a t t h e Downtown Community H e a l t h to  an  group.  t o reduce t u b e r c u l o s i s  among t h e s k i d - r o w p o p u l a t i o n , Control  r a t e s compared t o t h e  r i s k g r o u p , s k i d - r o w r e s i d e n t s , have y e t t o  area remains r e l a t i v e l y  In  627 p e r  thousand.  A l t h o u g h t h i s area has h i g h  be  was  Prior  hospitalVancouver  (VGH) w h i c h i s s i t u a t e d a b o u t 5 k i l o m e t e r s  from  the h e a r t o f t h e S t u d y A r e a . The DCHC  evolution  of community-based o u t - p a t i e n t  represent  Traditionally, based,  a new t r e n d  tuberculosis out-patient  prolonged  (18-24 m o n t h s ) ,  i n g e s t i o n o f two o r t h r e e DCHC,  treatment length  based,  supervised,  twice  weekly  unsupervised care-giver absolute  in tuberculosis  rather treatment  watches t h e p a t i e n t certainty  that  research.  b a s i s . However, a t t h e  ( u s u a l l y 9 m o n t h s ) , community-  f o r most p a t i e n t s daily.  mainly  treatment  the  chemotherapy i s h o s p i t a l -  d r u g s on a d a i l y  than  like  u n s u p e r v i s e d , and r e q u i r e s t h e  i s shorter  and  clinics  chemotherapy  (Supervissd  differs  because i n t h e former injest  t h e drugs so t h a t  the patient  2  has  occurs from  case  the  there  is  successfully  taken  treatment.) Shortening community,  length and  who  may  follow-up  must  variable  be  injestion  factors  stressed that  compliance  t h e DCHC,  t o appointments of drugs.  as  because  WCC p a t i e n t s a c t u a l l y major  terms  of  attendance among  e f f e c t i v e treatment 1.2  thesis,  patients  be  t h e most  the  dependant  to  treatment  opposed  treatment  c a n be c l o s e l y  There  linked  i s supervised, to  successful i s not  i s o n l y an i n d i c a t i o n  that  i s no way t o d e t e r m i n e w h e t h e r .  t a k e t h e m e d i c a t i o n s once t h e y go home.  o b j e c t i v e of t h i s t h e s i s  tuberculosis  residents  However, f o r t h e WCC, where t r e a t m e n t  have been p i c k e d - u p .  A  For these  This  outcome.  i n this  supervised, attendance t o appointments drugs  t o t h e drug regime.  a n d a t t e n d a n c e c o m p l i a n c e may  i n successful treatment  For  attendance  medications are treatment  poor and a l i e n a t e d .  i s attendance  compliance.  i n the  important f o r p a t i e n t s such as skid-row  important f a c t o r It  basing the c l i n i c  t o improving compliance  be a l c o h o l i c ,  ensuring  treatment,  supervising  geared p r i m a r i l y is particularly  of  compliance  i s t o e v a l u a t e t h e DCHC i n  because  with  high  rates  of  residents of skid-row i t i s imperative  that  i s available.  THE QUESTIONS:  Three new  primary questions a r e addresed  out-patient  patient  whether  out-  2)  Which  and t r e a t m e n t  f a c t o r s p r e d i c t compliance a t the  a n d ; 3) Who b e n e f i t s a n d who d o e s n ' t  t r e a t m e n t system?  1)Is the  t r e a t m e n t a t t h e DCHC b e t t e r t h a n t h e o l d  t r e a t m e n t a t t h e WCC i n t e r m s o f c o m p l i a n c e ?  socio-demographic DCHC?  in this thesis:  benefit  f r o m t h e new  The a n s w e r s t o t h e s e q u e s t i o n s w i l l  t h e DCHC i s e f f e c t i v e  determine  i n terms of compliance and i f 3  so  they w i l l to  provide direction  on how t o f u r t h e r  improve  compliance  treatment.  1.3  THESIS STRUCTURE:  Chapter  2  is  pathogenesis, discussion  an  and  introductory general  i s f o c u s e d on  discussion  tuberculosis  tuberculosis  of  tuberculosis  epidemiology.  epidemiology  The  i n developed  countries. Chapter history  3 of  i s a discussion tuberculosis  tuberculosis  treatment  outlined  the  The d e v e l o p m e n t o f c o m m u n i t y - b a s e d a n d h o s p i t a l - b a s e d  Study Area  5,  living  i n the Study Area  variables Section.  Chapter  Conclusions  8.  from c h a p t e r 2 and DCHC. of  used  i s sketched.  i n the study.  Results  the  City  encompasses  the  a p r o f i l e of the  Chapter  and d i s c u s s i o n a r e  Chapter  6  selection 7  i s the  presented  and recommendations a r e i n  o r d e r t o o r i e n t t h e r e a d e r and as p a r t of t h e  explained. the  outlined.  t h e e p i d e m i o l o g y and s o c i o - d e m o g r a p h y  Methodology  line,  is  a t c o m p l i a n c e and d e s c r i b e s t h e r a t i o n a l e b e h i n d  dependent  In  tuberculosis  i s d e s c r i b e d . A g a i n s t t h i s background  h i g h - r i s k group  of  out-patient  a n d c u l m i n a t e s w i t h a d e s c r i p t i o n o f t h e WCC  Chapter  looks  for  4 focuses the general treatment d i s c u s s i o n  o n t o B.C. In  systems  towards  show  treatment.  treatment  care  to  The  away  Chapter  in-patient  is  treatment.  evolution  out-patient  from  of  Chapter thesis  in 9. out-  g e o g r a p h i c and t e m p o r a l c o n t e x t of t h e study w i l l  be  The  of  S t u d y Arr.-. l i e s  of Vancouver. Vancouver's  w i t h i n the North Health Unit  The S t u d y A r e a was c h o o s e n skid-row.  The b o u n d a r i e s were  because they a r e c o n t i g u o u s w i t h t h r e e census  4  because  tracts  i t  choosen  (Tracts  57,  58  and  59) s o t h a t T.B.  r a t e s w i t h i n t h e Study Area  calculated.  Finally  population.  A map o f t h e N o r t h H e a l t h U n i t o f t h e C i t y  i s e n c l o s e d showing tracts  the  Study Area c o n t a i n s  the Study Area.  could  t h e DCHC's  target  Vancouver  W i t h i n the Study Area  57 ( S t r a t h c o n a ) 58 ( D o w n t o w n - E a s t s i d e )  a n d 59  be  census  (Downtown-  C o r e ) a r e d e l i m i t e d . ( A p p e n d i x A) D a t a were g a t h e r e d f o r t h e y e a r s 1977-79 a n d 1981-83. were g a t h e r e d f o r 1980 b e c a u s e the more  DCHC.  I t was f e l t  representative  operation.  Throughout  by  t h i s was t h e ' s t a r t - u p '  data  year f o r  t h a t t h e e v a l u a t i o n w o u l d be f a i r e r excluding  this thesis,  the c l i n i c ' s t h e term  1981-83.  5  first  year  'Study P e r i o d '  t o t h e s i x y e a r s f o r w h i c h d a t a were g a t h e r e d . and  No  That  is,  and of  refers 1977-79  CHAPTER  2.  TUBERCULOSIS EPIDEMIOLOGY 2.1  TUBERCULOSIS PATHOGENESIS: Pulmonary t u b e r c u l o s i s  which  is  usually  i s c a u s e d by M y c o b a c t e r i u m  transmitted  by  I n f e c t i o u s persons produce d r o p l e t s , the  bacterium.  remain  suspended  tuberculosis so  the  in  bacterium  and  air  is killed  environments. and  These d r y  the  best  living  tuberculosis  has  periods  in  O f t e n such c o n d i t i o n s  crowded  through coughing,  ultra-violet  survives  conditions  been  associated  tuberulosis  infection  droplet  resulting droplet  for long  by  airborne  tuberculosis  of  light  and  nuclei  time.  poorly  associated thus,  with  containing  M.  daylight  ventilated  with  not  can  The  including  dark,  are  nuclei.  poverty  surprisingly  slums,  poverty  and  the  inhalation  of  deprivation. Primary tubercle  bacilli  ingested Two  to  ten  hypersensitivity  injected  may lymph  may  be  intradermally  primary  observed  i n t o the  the  host  tuberculosis when  are  develops  antigens.  This  tuberculoprotein  host producing a s k i n  l e s i o n s i n the  However,  bacteria  t o r e g i o n a l lymph n o d e s .  infection  M.  The  lung  and  is  reaction.  local  t h e s e h e a l e d l e s i o n s may  t u b e r c u l o s i s o r g a n i s m s f o r many y e a r s .  provide and  to  tuberculosis  usually heal.  v i a b l e M.  transported  weeks a f t e r p r i m a r y  hypersensitivity  nodes  pulmonary a i r spaces.  by m a c r o p h a g e s and  cellular  The  i n t o the  follows  These  lymph contain lesions  i n n o c u l u m f o r s p r e a d t o o t h e r body s i t e s t h r o u g h  the  circulatory  for  r e a c t i v a t i o n of t h e  systems  disease.  6  and/or  be  the  source  When heal  primary t u b e r c u l o s i s  i n f e c t i o n occurs the l e s i o n s  and remain h e a l e d over t h e l i f e  I f however,  the primary  undernourished infection  or  may  lacks  resistance,  reactivated.  Clinical  u s u a l l y a r e a c t i v a t i o n of the primary within period The  weeks o f p r i m a r y  individual.  innoculum i s l a r g e and/or i f t h e host i s  otherwise  become  of t h e i n f e c t e d  usually  the  primary  tuberculosis  i n f e c t i o n w h i c h may  i n f e c t i o n b u t more o f t e n  is  follow  occurs a f t e r  a  of years. risk  exposure  of  primary  which  infection  i s d e t e r m i n e d by  i s determined  by  factors.  Thus,  p e o p l e who have h o u s e h o l d c o n t a c t  with active tuberculosis  cases  are  infection.  at highest  risk  environmental  entirely  for primary  However,  the  risk  f a c t o r s f o r r e a c t i v a t i n g t u b e r c u l o s i s d e p e n d s on many f a c t o r s . Some  of  the  malnutrition,  known  factors  renal  influencing  failure,  labile  reactivation  diabetes,  are  silicosis,  14 administration  of immunosuppresive drugs.  to r e a c t i v a t i o n disease major  factor  Deprived  with  Genetic  predisposition  h a s been d e m o n s t r a t e d i n t w i n s .  i n f a n t s and young  socio-economic  conditions  adults are also  least  Age i s a resistant.  associated  with  reactivation. 2.2 TUBERCULOSIS EPIDEMIOLOGY i n DEVELOPED NATIONS: Tuberculosis 1  is a  epidemiology varies  simple  tuberculosis  outlining  the  general  h a l " the  worlds'  population  i d e n t i f i a b l e by t h e i r n e g a t i v e t u b e r c u l i n  developed uninfected.  Figure  principles  of  epidemiology.  Approximately persons  model  i n different countries.  countries,  the majority  In developing countries 7  are  uninfected  rections.  In  of persons of a l l  ages  often  of a d u l t s  the majority  are  are who  i n f e c t e d so t h a t t h e are  "not  yet  uninfected  group c o n s i s t s  of  children  infected." FIGURE 1  A GENERAL MODEL OF  T.B.  EPIDEMIOLOGY.  TUBERCULOSIS I N F E C T E D Tuberculin Positive.  NOT I N F E C T E D Tuberculin Negative. Source: Daniel, T.M., "Selective Primary Health Care: S t r a t e g i e s f o r C o n t r o l of D i s e a s e i n t h e D e v e l o p i n g W o r l d , I I : Tuberculosis." Reviews of I n f e c t i o u s Diseases, 6:12541265, 1982, (14). I n f e c t e d persons a r i s e from the Section Once  2.1  the  exposure  factors  often  conditions.  has  for primary  occurred  tuberculosis.  In  the  United  approximately  5%  of  States,  countries  where i n c i d e n c e  r i s k of e x p o s u r e i s h i g h .  Risk  for  nations.  the poor i n d e v e l o p i n g  control  and  in  exposure. on  poor to  host living  develop  indicate  subsequently  that  develop  tuberculosis.  In d e v e l o p i n g  poorly  goes on  studies  persons  stated  depends  m a l n u t r i t i o n and  i n f e c t e d pool  infected 14  As  i n f e c t i o n depends on  l i n k e d with poverty, i n the  with  group.  reactivation risk  portion  reactivation  A  risk  uninfected  organized  r a t e s can  of r e a c t i v a t i o n may  be h i g h , a l s o be  high  These f a c t o r s i n c o m b i n a t i o n  h e a l t h s e r v i c e s pose d i f f i c u l t i e s  e r a d i c a t i o n of the d i s e a s e 8  the  p a r t i c u l a r l y as a  for  .the  higher  percentage  of  conditions  tuberculosis  where t h e d i s e a s e  or remains u n t r e a t e d In  until  developed countries  "There the  cases  decreasing figures wars,  from  the  problem  in  to  and  of  specific  downward t r e n d  the  introduction  that  post-chemotherapy  living  reduced the main  arises which  this  has 39  century."  i n f e c t i o n r a t e s were year.  of  a b o u t 5%.  been  Reliable two  world  decreasing  These d e c r e a s e s were conditions 39  This  r a t e has  c h e m o t h e r a p y so t h a t  at  likely  rather  than  increased  infection  the  since  rates  12-13%  in  annually.  t h e d i f f e r e n c e between t h e p r e - c h e m o t h e r a p y i n f e c t i o n rates  chemotherapy i n these  the  t u r n of  i t ' s magnitude,  countries  c o u n t r i e s have d e c l i n e d a t a r a t e of  is likely  High  developed  different.  i n t u b e r c u l o s i s i n f e c t i o n r a t e s p r i o r to  of c h e m o t h e r a p y was  developed  treated  c o n t r o l measures.  era  and  quite  i r r e s p e c t i v e of  improvements i n socio-economic  institution  It  is  f r o m t h e N e t h e r l a n d s i n d i c a t e t h a t between t h e rates  under  inadequately  epidemiology  a t l e a s t the  mortality  The  infectious  i t r e a c h e s an a d v a n c e d s t a t e .  a r a t e of a p p r o x i m a t e l y 5% per due  be  i s untreated,  i s r e l i a b l e evidence that tuberculosis  may  i s due 39  t o enhanced  and  case-finding  countries.  standards,  good c a s e - f i n d i n g and  treatment  have  r i s k of exogenous i n f e c t i o n i n d e v e l o p e d c o u n t r i e s c o n t r i b u t i o n to tuberculosis  in  t h r o u g h endogenous e x a c e r b a t i o n are already  infected.  m a i n l y of o l d e r p e o p l e ,  of t h e d i s e a s e  In C a n a d a ,  i m m i g r a n t s and  9  developed  these  so  countries in  cohorts  a b o r i g i n a l people.  cohorts consist  2.3  THE COHORT E F F E C T : One o f t h e most i n t r i g u i n g  (particularly People of  i n developed c o u n t r i e s )  bacterium  T.B.  r a t e s were a t g r e a t e r  and subsequent p r i m a r y  Saskatchewan  the  i s the  i n developed c o u n t r i e s born i n those  higher  1955  f a c e t s of t u b e r c u l o s i s  study  province.  In  the  reactions increased with positive  reactions.  'cohort  effect'.  c o u n t r i e s i n an e r a  r i s k of exposure  infection.  u s i n g mass t u b e r c u l i n  to develop a t u b e r c u l i n 4  epidemiology  to the  T h i s was shown i n a testing  r e g i s t r y of p o s i t i v e  mid-60's t h i s r e g i s t r y  starting  in  reactors  in  showed  positive  i n c r e a s i n g a g e . F o r a g e s 0-14, 1% showed  F o r a g e s 15-19,  4.4% were p o s i t i v e a n d f o r  a g e s 20-29, 11.5% were p o s i t i v e r e a c t o r s . The i n c r e a s e was reaching  a maximum o f 5 5 % f o r t h o s e  Clearly, age  the  the  larger  probablility  a g e d 60 a n d o v e r .  p r o p o r t i o n of i n f e c t e d cases i n c r e a s e d w i t h the  of t h e c o h o r t .  that  From t h e m o d e l i n F i g u r e  s u r p r i s e that i n developed c o u n t r i e s  greater  the  i s therefore  no  (where t h e r o l e o f e x o g e n o u s  i n o l d e r segments of t h e p o p u l a t i o n born  in  country.  The result  risk of  o f endogenous r e a c t i v a t i o n f o r o l d e r c o h o r t s high  exposure t o primary  infection  i m m i g r a n t s f r o m c o u n t r i e s w i t h h i g h T.B. countries these  It  the  clear  h a s been r e d u c e d ) t u b e r c u l o s i s i s p r i m a r i l y seen a s  reactivation disease that  1 i ti s also  the pool of i n f e c t e d people  f o r r e a c t i v a t i o n s t o occur.  re-infection  steady  i m m i g r a n t s had h i g h e x p o s u r e t o p r i m a r y  10  i n .youth.  When  r a t e s move t o d e v e l o p e d  w i t h low r a t e s a s i m i l a r phenomenon  y o u t h even a f t e r t h e y move t o a c o u n t r y  is a  i s observed. infection  If  in their  w i t h low r a t e s t h e y  tend  to e x h i b i t high This  r a t e s o f endogenous r e a c t i v a t i o n .  was shown r a t h e r  elegantly  i n a s t u d y by E n a r s o n , 19  and  G r z y b o w s k i o f F i n n i s h i m m i g r a n t s t o Canada.  the  1970-72  incidence  r a t e s of F i n n i s h  Canada and c o m p a r e d them w i t h has  historically  rates  had h i g h e r  study  r a t e s than Canada.  Canada  an  Finland. among  showed t h a t F i n n i s h average  The  Finland  i m m i g r a n t s who  T.B.  had  lived  in  to  those  in  authors of t h i s study concluded that higher  were due t o i n c r e a s e d  exposure during  rates  In  group.  higher  a s r a t e s among t h e F i n n i s h  rate effect  immigrants  a b o r i g i n a l p e o p l e s c o n s t i t u t e a n o t h e r major Because  mortality  and i n c i d e n c e  f o r a b o r i g i n a l people than the  born p o p u l a t i o n , the  (The c o h o r t  in  s t e a d i l y w i t h age o f t h e c o h o r t . )  Canada,  risk  t h e i r youth  and subsequent endogenous r e a c t i v a t i o n a t a h i g h e r  increased  there  aboriginal  population. were h i g h  Also,  because  rates  non-aboriginal  i s a proportionately  population  so r e c e n t l y ,  y o u n g e r age c o h o r t s .  compared  to  the  Canada,  aboriginal  much  Canadian-  non-aboriginal  rates f o r the a b o r i g i n a l  the l e v e l of primary  were  high-  l a r g e r i n f e c t e d group  population  infection  i s high i n  T h u s , t u b e r c u l o s i s among C a n a d i a n  aborigines  t o occur i n younger age-groups than f o r t h e  Canadian-born In  I n 1970-72  of 40 y e a r s h a d r a t e s s i m i l a r  s u p e r i m p o s e d on t h i s ,  tends  (Finland  rates.)  i n Canada t h a n t h e C a n a d i a n - b o r n p o p u l a t i o n .  in  in  F i n n i s h i m m i g r a n t s t o Canada compared t o t h e C a n a d i a n - b o r n  population  was  living  in Finland.  i n F i n l a n d were a b o u t 7 t i m e s C a n a d i a n  The  They c a l c u l a t e d  immigrants  1970-72 r a t e s  Sjogren,  non-aborigLnsl  population. older  members  of t h e  Canadian-born  p e o p l e s and immigrants from c o u n t r i e s 1 1  population,  with high  T.B.  rates  a r e some of t h e m a j o r  high-risk likely groups. for  groups  socio-demographically  for tuberculosis.  Endogenous r e a c t i v a t i o n  t h e m a j o r mechanism o f t u b e r c u l o s i s  presentation  T h e r e f o r e any f a c t o r s w h i c h i n c r e a s e  reactivation  of c a s e s w i t h i n  (like  poverty) w i l l  these h i g h - r i s k  likely  groups.  1 2  identifiable  host  in  is  these  susceptibility  increase  the  number  CHAPTER 3. THE EVOLUTION OF TUBERCULOSIS TREATMENT 3.1  INTRODUCTION:  The  purpose  of t h i s  broad h i s t o r i c a l  chapter  context.  in t u b e r c u l o s i s treatment  i s t o p l a c e t h e DCHC a n d  That i s ,  to describe  in  the developments  w h i c h have l e d t o o u t - p a t i e n t  b a s e d a t h o s p i t a l s ( l i k e t h e WCC) o r i n l o c a l  WCC  services  communities.  (like  t h e DCHC) 3.2 THE PRE-MODERN ERA AND TUBERCULOSIS TREATMENT: Tuberculosis Moorman, that  "  T.B.  i s a disease of great  The may  s e r i o u s study have  been 30  antiquity.  According  of h i s t o r y j u s t i f i e s  the f i r s t  born  of  the  to  belief  t h e mother  of  p e s t i l e n c e and d i s e a s e . " Tuberculosis Physicians widely used  was  in  t h e r e f o r e w e l l known t o p r e - m o d e r n  different  varying treatments a  c u l t u r e s of the ancient t o cure  the disease.  h y g i e n i c - d i e t e t i c treatment  The  improve  Indo-Aryans  the  general  treatments  s o t h a t " i n I m p e r i a l Rome i t became t h e c u s t o m t o s e n d  it  practiced  used  of  afflicted  The Romans  world  condition  people  patients.  to  peoples.  climotherapeutic  w i t h p u l m o n a r y m a l a d i e s t o S i c i l y and E g y p t 16  was w e l l known t h e y A varying mixture  would o f t e n r e t u r n  of d i e t e t i c ,  as  cured."  c l i m a t i c and o c c u l t cures  were  a d v o c a t e d by t h e p h y s i c i a n s o f a n t i q u i t y a n d E u r o p e i n t h e M i d d l e Ages.  During  the Renaissance  t u b e r c u l o s i s m i g h t be c o n t a g i o u s In  i n Europe, began t o g a i n  t h e concept credence.  1546 a F l o r e n t i n e p h y s i c i a n Hyeronymus F r a c a s t o r i u s  expressed  a  theory  on t h e i n f e c t i v i t y 13  and  that  clearly  contagiousness  of  tuberculosis generally belief  i n h i s book De  accepted  so t h a t  making  tuberculosis procedures  live patients. in  i n S o u t h e r n E u r o p e and  in parts  disinfectant  S p a i n and However,  a  reportable  theory  attained  disease  as  a  promulgated  and  encouraging  tuberculosis  corpses  l a w s were r i g o r o u s l y  physicians  tended  h e d i t a r y - f a m i l i a l disease  These p h y s i c i a n s  sunny s k i e s c o u l d  the  s a p p i n g of s t r e n g t h  c e r t a i n death i n the  Koch, demolished the  believed  that  and  enforced  regard  scorned  of  lung  tissue  consumptive  bacilli  i n 1882  h e r i d i t y t h e o r y of t u b e r c u l o s i s c a u s e d by  by  origin.  sanatorium  fact,  sanatorium  based  treatment dominated the  of t h e modern e r a  first  OF  TUBERCULOSIS TREATMENT:  modern  era  in tuberculosis  two  periods.  The  first  saw  the  development of of  sanatoria  s t a r t e d a f t e r W o r l d War the  In  period  1882,  t r e a t m e n t of  t r e a t m e n t can  be d i v i d e d  into  1945  and  l a s t e d f r o m 1882  until  s u r g i c a l t e c h n i q u e s and  to t r e a t t u b e r c u l o s i s . II with  s u b s e q u e n t d e v e l o p m e n t of  1.Surgical  of  treatment.  MODERN ERA  building  period  Once  germ,  In  The  to  a  t r e a t m e n t methods began t o d e v e l o p .  THE  and  Robert  based  3.3  the  years."  tubercule  r e a l i z e d t u b e r c u l o s i s was  to  " r e s t , balmy a i r  o t h e r w i s e drove the 16  s p a c e of a few the  and  that  a r r e s t the d e s t r u c t i o n  i d e n t i f i c a t i o n of  tuberculosis  was  widespread  S p a i n l a w s were  for handling  European  and  people  I t a l y and  This  Italy.  contagion theory.  The  of  These p u b l i c h e a l t h 16  Northern  tuberculosis  Morbis Contagiosis.  the d i s c o v e r y  tuberculosis  the  The of  widespread  second  period  streptomycin  and  chemotherapy.  tuberculosis.  Forlanini first  induced a r t i f i c i a l 14  pneumothorax  or  the  surgical  c o l l a p s e of the l u n g .  49  I t took  30 y e a r s f o r  this  s u r g i c a l method t o g a i n t h e m e d i c a l e s t a b l i s h m e n t ' s s u p p o r t .  The  rationale  it  allowed  behind  surgical  of t h e l u n g  time f o r the t u b e r c u l a r l e s i o n s t o  expanded i n the e a r l y pneumothorax surgery half  collapse  surgery.  was  of  twentieth century, A  the normal  the  mixture  treatment  twentieth  was  heal.  that  As  sanatoria  so d i d t h e f r e q u e n c y  of s a n a t o r i u m  treatment  and  f o r t u b e r c u l o s i s f o r the  century u n t i l  the  widespread  of  first use  of  started  by  a n t i b i o t i c s i n the mid-1950's. 2.Sanatoria. The  first  sanatorium  f o r t u b e r c u l o s i s t r e a t m e n t was 14  Hermann Brehmer i n Germany i n 1854. tuberculosis  infectivity  b u i l d i n g movement. pronged cure  infective  arrest people  demonstration  l e n t enormous i m p e t u s  t h e d i s e a s e and  by K o c h of  t o the  motivation for building  a f t e r Koch's d i s c o v e r y .  or  In  The  The  sanatorium  s a n a t o r i a was  Firstly,  sanatoria could  secondly  they  helped  two help  isolate  from h e a l t h y p e o p l e .  Trudeau's 14 sanatorium a t Saranac Lake, New Y o r k w h i c h he b u i l t i n 1884. The f i r s t C a n a d i a n s a n a t o r i u m was b u i l t s h o r t l y t h e r e a f t e r i n Muskoka 16 in  North America,  s a n a t o r i a were m o d e l l e d  on  Dr.  1896. In  The  Canada s e v e r a l p h a s e s of s a n a t o r i a d e v e l o p m e n t a r e first  often  s t a g e saw  t h e b u i l d i n g of s a n a t o r i a i n r u r a l ,  d r y and m o u n t a i n o u s a r e a s .  Kamloops i n B r i t i s h C o l u m b i a As  the  Canadian  epidemiology  shifted  was  population  The  urbanized  15  isolated,  T r a n q u i l l e sanatorium  b u i l t during t h i s era  from a r u r a l  apparent.  and  t o an u r b a n  as focus  near  (1908).  tuberculosis the  second  stage  of  sanatorium  development u n f o l d e d  stage,  s a n a t o r i a were b u i l t  larger  u r b a n c e n t r e s began i n t e g r a t i o n  Tuberculosis integration relative  treatment with  sanatoria  Canada.  As  sanatoria  t h i s stage  i n remote  societies  funding  centres  played  increased, relegating and  Canada's  provinces  was  in  hospitals.  beginning  a major r o l e  twenty years  i t ' s  began  voluntary  society  tuberculosis education. B.C.)  setting  reof  up  and  of t h e c e n t u r y  in  running  provinces  (including  in  to  b u i l d i n g of s a n a t o r i a i n the f i r s t  over  activities  By t h e had  tuberculosis  take  1930's,  their to  of  direct 7  treatment.  h a l f of  was a c c o m p a n i e d by t h e a l m o s t m e s s i a n i c  fund  half  established  p r o v i n i c i a l government c o n t r o l o v e r t u b e r c u l o s i s  century  this  sanatoriums.  i n the f i r s t  raising  The  In  o f p o p u l a t i o n and  with general  t h e c o s t s and c o m p l e x i t i e s o f  management  Canada.  mainstream medicine a f t e r n e a r l y a century  isolation  Voluntary  by  nearer  in  the  twentieth  educational  and  o r g a n i z a t i o n a l z e a l of t h e v o l u n t a r y a n t i - t u b e r c u l o s i s s o c i e t i e s . These  societies  facilities.  This  raised era  money f o r t u b e r c u l o s i s also  saw t h e d e v e l o p m e n t o f  p r o g r a m s a n d t h e d i s c o v e r y o f t h e BCG v a c c i n e efficient of  c a s e f i n d i n g and p r e v e n t i o n  increased case f i n d i n g  ,  education  increased  which  measures.  The  mass  and  X-ray  l e d to  more  interaction  i s o l a t i o n and t r e a t m e n t  s a n a t o r i a and i n c r e a s e d w e l l - b e i n g and r e s i s t a n c e of t h e population  and  in  general  c o i n c i d e d with a decrease i n t u b e r c u l o s i s death  rates  prevalence.  However,  i t wasn't u n t i l a f t e r t h e war t h a t t u b e r c u l o s i s r a t e s  went i n t o d r a m a t i c  decline.  16  3.Chemotherapy. The  second  discovery  era  in  modern  of streptomycin  treatments  T.B.  treatment  i n 1944.  By 1945,  that  discovery of 49  1952. of  first  the human  and by 1947 t h e 49 chemotherapy.  o f s t r e p t o m y c i n was q u i c k l y f o l l o w e d  para-aminosalicylic  These t h r e e the  the  with  were c a r r i e d o u t a t t h e Mayo C l i n i c  d r u g was a v a i l a b l e i n Canada f o r t u b e r c u l o s i s The  began  1950's  acid  (PAS) and i s o n i a z i d  d r u g s became t h e p h a r m a c o l o g i c a l and  60's  in  ( i n 1946) by  the  world-wide  (INH) i n  armamentarium  drive  to  cure  tuberculosis. Streptomycin eighth and  had  toxic  to the  c r a n i a l n e r v e a n d i n some p a t i e n t s c a u s e d l o s s o f  balance  deafness  and  intramuscular resistance  disadvantages  because  injection to  on  because i t i s  i t had a  daily  to  be  administered  basis.  Also,  t h e d r u g became common when t h e  drug  by  bacterial was  given  alone. Combination  regimes  using  streptomycin,  PAS,  and  INH  developed t o reduce occurence of b a c t e r i a l r e s i s t a n c e . and  most o t h e r c o u n t r i e s ,  the  5 0 ' s and 60's c o n s i s t e d  of t h e s e d r u g s l a s t i n g therapy  was  mainly  of a d a i l y regime w i t h a  f o r 18 t o 24 months.  medical attain  use  sanatorium  sanatoria.  on an o u t - p a t i e n t  was b e g i n n i n g t o become  j u s t a f t e r W o r l d War 2 i t t o o k n e a r l y  generalized patients  use i n Canadian s a n a t o r i a .  By  basis.  available a  the  for  decade  to  I n 1947 0.01%  of  were r e c e i v i n g s t e p t o m y c i n . 17  combination  I n t h e 40's a n d 5 0 ' s  c a r r i e d out w i t h i n the  streptomycin  I n Canada  s t a n d a r d t u b e r c u l o s i s chemotherapy i n  1960's d r u g s were i n c r e a s i n g l y g i v e n Although  were  By  1954  this  percentage  74% o f  patients  were  patients  were  receiving  50% o f s a n a t o r i u m 36 INH. T h i s went up t o 84% by 1959.  Canadian  and  also  had  increased  receiving  accordingly.  PAS.  B.C.  t o 81%.  By  By  1954  1956  death  rates  for  tuberculosis  responded  ( T a b l e 1)  TABLE I : T u b e r c u l o s i s D e a t h R a t e s i n Canada and B . C . ( p e r 100,000) YEAR  CANADA  1945 1952 1 962 1972 1982 Problems apparent  47.2 17.6 4.2 2.1 0.6  of to  bacterial clinicians  tuberculosis  55.3 17.8 2.9 1 .8 0.5  r e s i s t a n c e and after  chemotherpy.  research into less-toxic in  B.C.  a  These  few  drug  toxicity  years  problems  experience gave  which  met  with  impetus  for  t u b e r c u l o c i d a l drugs t h a t would a l o n e or  c o m b i n a t i o n s be p o w e r f u l enough t o p r e c l u d e d r u g  I n t h e 1960's,  became  two d r u g s were f o u n d  some of t h e s e p r o p e r t i e s .  resistance.  ( e t h a m b u t o l and  rifampicin)  A f t e r development  of  these  drugs d a i l y combination treatment u s i n g ethambutol, r i f a m p c i n  and  INH became p o p u l a r . Rapid  i n t r o d u c t i o n of c h e m o t h e r a p y and  i t ' s subsequent  effect  on t u b e r c u l o s i s d e a t h r a t e s began t o have d r a m a t i c e f f e c t s on established  tuberculosis  expanding p r i o r 1947  there  provincially  treatment system.  Sanatoria  had  the been  t o chemotherapy f o r t u b e r c u l o s i s . For example,  were  3.32  million patient  run s a n a t o r i a .  days  spent  T h i s f i g u r e peaked  patient-days  i n 1953 and d e c l i n e d 37 d r o p o f more t h a n 60%.  18  t o 2.43  in  in  Canadian  a t 6.22  million  million  by  1961,  a  Although general  it  was  cheaper to t r e a t p a t i e n t s  hospitals,  response  to  efficiency  lowered  the  tuberculosis  d e c l i n e was  b e c a u s e of t h e of  new  stay  r e a d m i s s i o n s was 37  rates  shortened length  of  By  1961,  than  sanatoria  did  their  stay  in  first  t h i s had  in  fiscal  Another f a c t o r  in  institutions  e x a m p l e , i n 1954  f o r Canadian t u b e r c u l o s i s days.  so  hospitals.  chemotherapy. For  394  sanatoria  occupancy dropped i n  in r e l a t i o n to general  sanatoria  length  as  in  the  average  admissions  and  been h a l v e d t o  199  days. Clearly,  by  standards  of  sanatoria. in  patient  of  stay  r a p i d l y so longer  in  Also,  new  rising  Canadian  d a y s and  decreases  drugs  rendered  s a n a t o r i u m - b a s e d a d v a n t a g e s of  a major c o n c e r n .  r e i n t e g r a t i o n of  mainstream  felt  number of p a t i e n t  reduced occupancy.  non-infective  the  i m p a c t of c h e m o t h e r a p y and  were m a k i n g t h e m s e l v e s  i s o l a t i o n were no  speeded with  living  R e d u c t i o n i n the  length  patients  the mid-50's the  tuberculosis  These  factors  treatment  medical treatment services offered  services  in  general  hospitals. This  r e i n t e g r a t i o n p r o c e s s was  Canadian offered the  Hospital 50%  cost  provinces'  services  sharing  into  a general  of  1957.  for general  best f i n a n c i a l  support from the This  Insurance Act  h a s t e n e d by  This  act  i n t e r e s t s to integrate  h o s p i t a l in order to receive  c h a n g i n g r e a l i t y was Services  officially chaired  i n the  C o m m i s s i o n ' s 1965  publication  it's  conclusions  authors  the  passing  19  of  the  essentially  h o s p i t a l s e r v i c e s . I t was  f e d e r a l government under t h i s  C o m m i s s i o n on H e a l t h  the  financial  by  the  Royal  J u s t i c e Emmett H a l l  'Tuberculosis  recommended  tuberculosis  act.  recogr.i,:ed  by Mr.  in  that  i n Canada'. In tuberculosis  services  "  medical be  should  be  integrated  into  s e r v i c e s where p o s s i b l e " and  included  Government  and  general  that " t u b e r c u l o s i s  i n the p l a n f o r h o s p i t a l s e r v i c e s w i t h the participation  7  community  to  the  same  extent  as  should Federal  for  other  diseases." These  general  epidemiological  occuring  throughout  However,  most  of  c h e m o t h e r a p y had The  people.  industrialized  innovative  of  to  poverty  had and  Medical  i n the developed  a  d i s e a s e of  numerous  on  relegated  marginal,  authors  stated:"  medical  staff  of  more  death  in  for tuberculosis services.  a t t r a c t young, w e l l - t r a i n e d m e d i c a l  Kenya  of  Chemotherapy  Hong Kong. Centre  A 1959  relative to  In t h i s r e p o r t  maintaining  to the the  competent  T u b e r c u l o s i s does 7  not  personnel."  the d e v e l o p i n g c o u n t r i e s  t u b e r c u l o s i s r e s e a r c h i n t h e 50's  and  services.  apparent  t h e p r o v i n g g r o u n d f o r t u b e r c u l o s i s c h e m o t h e r a p y . The loci  and  c o u n t r i e s waned  rates increased  There i s d i f f i c u l t y  60's  urban  generalized  health  i n t u b e r c u l o s i s i n developed  1950's and  usually  tuberculosis case-finding  R o y a l C o m m i s s i o n on H e a l t h S e r v i c e s i n 1965.  the  tuberculosis  countries rapidly  problems because  d i s e a s e and c a n c e r  by  world.  post-war  f o r t u b e r c u l o s i s . T h i s l a c k of i n t e r e s t was  Thus,  were  increased  poor,  and  t h e r e l a t i v e u n d e r d e v e l o p m e n t of interest  heart  trends  'developed'  research  chemotherapy  In developing c o u n t r i e s ,  treatment  treatment  s h i f t e d to developing countries.  of l i v i n g  tuberculosis  those  the  combination  standards  as  the  and  study at the  and  60's  became  t h r e e major were  India,  Madras  Tuberculosis  compared outcome f r o m s t a n d a r d  tuberculosis  20  chemotherapy  administered 45  administered the  a t home.  impoverished  in  The s t u d y  a  hospital  clearly  showed  and  self-  t h a t even  with  home c o n d i t i o n s of many o f t h e M a d r a s p a t i e n t s ,  hospitalization  was  not  necessary  to  treat  pulmonary  tuberculosis. This  study  established  chemotherapy treatment  not  outcome  results  only possible  and  cost  but  based  tuberculosis  advantageous  p o i n t of view.  The  to  treatment.  Centre  supervised chemotherapy 46,47 fully.  during  the  1960's  focused  out-patient  efforts  on  of  these  equality  Madras  of supervised  studies  a  study  at the  development  intermittent as opposed to unsupervised r e g i m e s i n an e f f o r t t o make p a t i e n t s c o m p l y  Results  therapeutic  Subsequent r e s e a r c h  from  Madras  a l s o h i g h l i g h t e d the importance of e n s u r i n g  compliance Madras  was  that out-patient  of  daily more  established  i n t e r m i t t e n t treatment  the with  unsupervised d a i l y out-patient treatment. Similar results were obtained i n c o n t r o l l e d studies at other research centres i n the 15,50 60's a n d 7 0 ' s . In  the  1970's t h e r e s e a r c h  traditional in  1968  i t ' s efficacy  p o s s i b i l i t y of shortening  Medical Hong  tested  showed  chemotherapy  shortening  The d i s c o v e r y  against  tuberculosis  the t r a d i t i o n a l  i n Kenya,  various  l e n g t h of  that  Tanzania  combinations 18,27  d r u g s f o r p e r i o d s o f 6 a n d 9 months. clearly  to  the  of r i f a m p i c i n raised  the  tuberculosis  C o n t r o l l e d t r i a l s under s u p e r v i s i o n o f t h e B r i t i s h  Research Council Kong  shifted  l e n g t h of chemotherapy.  and  chemotherapy.  focus  By t h e  intermittent  (then Tanganyka) and of  anti-tubercular  mid-70's,  supervised  research  out-patient  f o r p e r i o d s a s s h o r t a s 6 months were e f f e c t i v e 21  in  treating The  tuberculosis  evolution  treatment  in developing  of  countries.  shortened i n t e r m i t t e n t  out-patient  systems f o r t u b e r c u l o s i s h i g h l i g h t e d the  p a t i e n t c o m p l i a n c e . These t r e a t m e n t methods a r e patients number  took of  therapy  the m e d i c a t i o n .  studies (See  This  on c o m p l i a n c e  C h a p t e r 6) and  to  importance  only  realization  on  of  effective if  resulted  tuberculosis  emphasis  based  in  a  out-patient  designing  treatment  s y s t e m s t h a t promote c o m p l i a n c e . Even  t h o u g h h a r d d a t a b a s e d on developing  relatively  populations  in  traditional  t u b e r c u l o s i s c h e m o t h e r a p y were i n  countries  were  treatment  systems.  industrialized tuberculosis Association  North  first  trial,  relapses of  12  Arkansas INHof  Thus  recommended  'racalcitrant'  new  Britain.  to  t r i a l of  the  use  of  in  1967  tuberculosis patients twice  w e e k l y INH  changes  order,  one  the  in  developed  to  their  of  the  adopt  own first  intermittent  British  Thoracic  short-courseintermittent  intermittent supervised  occurred  using  that  findings  C z e c h o s l o v a k i a was  13  on  25  mainly  i n Denver, and  chemotherapy  alcoholic  Colorado.  streptomycin,  in  This  showed  no  and  no t r e a t m e n t f a i l u r e s a f t e r median t r e a t m e n t length 34 m o n t h s . In 1976 a l a r g e r s c a l e s t u d y was undertaken in t o t e s t the  e f f i c a c y of tw"ce weekly  r i f a m p i c i n treatment this  adapt the  showed  officially 32 c h e m o t h e r a p y i n 1972. I n 1976  America  small  to  countries  chemotherapy i n The  slow  countries  difficult-to-treat  s t u d y were t h a t 17 economical.  o v e r a 9 month p e r i o d . s u c h t r e a t m e n t was  22  safe,  self-administered The  conclusions  effective  and  Although Europe,  some t r i a l s  Fox  advanced  claims  methods  have been c o n d u c t e d i n N o r t h  that  developing  nations  of c h e m o t h e r a p y w h e r e a s  not.  reason  he  and  using  new  are  technically  are  situation  i s t h a t t h e t e c h n i c a l l y a d v a n c e d c o u n t r i e s pay  attention  to  p u b l i c a t i o n s and  offers  reason  powerless the  eradicate that  although  in  area  1985  for years,  advent death  get  had  the  i n developed available  relatively countries, to  i t is interesting  been a  problem  in  finally to note  Vancouver's  i t received widespread press a t t e n t i o n were middle  disease.)  the  e r a was  one  North-America. combination  of the l e a d i n g  of  w e l l - b e i n g of t h e g e n e r a l  rising  living  p o p u l a t i o n and  d i s e a s e u n d e r c o n t r o l i n most d e v e l o p e d remained r e l a t i v e l y  causes  W i t h i n a decade a f t e r  r e v o l u t i o n i z e d tuberculosis epidemiolology  disease  Another  t u b e r c u l o s i s i s an a n c i e n t d i s e a s e w h i c h u n t i l  i n E u r o p e and  increased  control).  have  T h a t i s , , t u b e r c u l o s i s i s news when  of t h e a n t i - b i o t i c  introduction,  light  little  b e c a u s e M i n i s t r y o f Human R e s o u r c e s w o r k e r s  g e t t i n g the d i s e a s e .  In summary,  (In t h i s  t u b e r c u l o s i s has  mainly  c l a s s people  sub-populations  a r e s i m p l y not b e i n g made  the d i s e a s e .  Downtown  T.B.  unusual  (which 24  i s that w i t h the d i s e a s e c o n f i n e d to  often marginal  resources  this  recommendations  been t h e f o r u m f o r most d e v e l o p m e n t s i n possible  for  advanced  countries  WHO  One  America  intractable  the of  their  standards, anti-biotics  and  brought  the  countries.  However,  the  i n the c r u s h i n g  poverty  o f most d e v e l o p i n g c o u n t r i e s . Research late had  e f f o r t s s h i f t e d to the developing  n a t i o n s and  1960's o u t - p a t i e n t b a s e d c h e m o t h e r a p e u t i c t r e a t m e n t been t e s t e d and  the concept of 23  by  the  systems  i n t e r m i t t e n t chemotherapy  for  tuberculosis in the late  had been e s t a b l i s h e d .  The d e v e l o p m e n t o f new d r u g s  1960's l e d t o e s t a b l i s h m e n t of s h o r t - c o u r s e  treatment  r e g i m e s by t h e mid 1970's. North-America innovations. treatment  was Slowly  relatively as  slow  sanatoria  came under g e n e r a l  in  introducing  closed  and  these  tuberculosis  hospital control,  t r e a t m e n t became  more o u t - p a t i e n t  b a s e d . The n e x t c h a p t e r t r a c e s  this evolution in  B.C. c u l m i n a t i n g  w i t h a d e s c r i p t i o n o f t h e WCC  24  and DCHC.  CHAPTER  4.  TUBERCULOSIS CONTROL IN 4.1  B.C.  EARLY Y E A R S : Efforts  the  to c o n t r o l  turn  of  Prevention was  and  formed.  of  the  In  legislature.  Tranquille  tuberculosis  century.  In  i n B r i t i s h Columbia  1904  1907  the  B.C.  i n the  the  Tranquille  C h e s t was  along with  s e t up  the  1 swelled  province,  THE The  and The  f o r m e d by  early  of  campaign,  1918  the  act at  D I V I S I O N OF  had  T.B.  been  s e t up  voluntary the  B.C.  sanatorium. f o c a l point  clinic  treat However,  c o n t r o l and  of  the  development  was  T.B.  patients  their role  was  t r e a t m e n t was  i n the  dry  largely  to  i n t e r i o r of the  in the  voluntary  Tranquille.  CONTROL Control  h e a d q u a r t e r e d at the Willow. S t r e e t was  T.B.  Rotary I n s t i t u t e for Diseases  left  D i v i s i o n of T u b e r c u l o s i s  Division  numbers of  Tranquille.  1930's t u b e r c u l o s i s  Education  the  i n 1919  the  i n Vancouver to  s o c i e t i e s a l s o c e n t e r e d at 4.2  was  s t r a i n i n g the  s a n a t o r i u m was  p r o v i n c i a l government c o n t r o l c e n t e r e d province.  T.B.  Accordingly,  Vancouver General H o s p i t a l .  minor compared t o t h a t By  O t h e r Forms of  a sanatorium b u i l t  of T r a n q u i l l e  anti-tuberculosis  b e g i n n i n g i n Vancouver. In the  the  near Ramloops.  government t o o k o v e r o p e r a t i o n  of  and  begun and  f i n a n c i a l resources.  province's  for  Society  Anti-T.B. Society  Fund r a i s i n g was  cases needing treatment  Although  at  B.C.  T r e a t m e n t of C o n s u m p t i o n  R e t u r n i n g v e t e r a n s f r o m W o r l d War  society's  the  began  by  the  25  was  established  in  1935  Chest Centre i n Vancouver.  p r o v i n c i a l D e p a r t m e n t of  Health  and  r e c e i v e d most of i t ' s f u n d i n g f r o m t h e p r o v i n c i a l  I n 1936, from of  t h e T r a n q u i l l e T.B.  S o c i e t y was  T r a n q u i l l e to Vancouver to a s s i s t fund  r a i s i n g and  treatment  and  from r u r a l  isolation  I n 1949 the  was  in  1952  it's  i n B.C. peak.  biotic  Control for  i n terms  Tuberculosis  control,  general hospital  (Pearson H o s p i t a l ) i n  director has  stated:  YEAR 1 952 1 955 1958 1 961 1 963 1964  Vancouver.  the  corresponds  new  At  this  C o n t r o l Report  system  f o r 1953  a  " D u r i n g t h e r e c e n t months an  empty b e d s and a l l c a s e s  could  at anti-  be a d m i t t e d  P o p u l a t i o n i n B.C.  of  T.B. except 40  immediately." was  dramatic  as  1952-1964.  TOTAL POPULATION i n B.C.  SANATORIA.  838 615 332 244 205 163  S o u r c e : The D i v i s i o n of T u b e r c u l o s i s C o n t r o l , P r o v i n c e of C o l u m b i a . A n n u a l R e p o r t , 1965. Over  of  a  the treatment  i n s a n a t o r i u m p o p p u l a t i o n i n B.C.  shown i n T a b l e I I . TABLE I I . S a n a t o r i a  of  been p e r c e i v e d a t t h e D i v i s i o n  i n t h a t t h e r e have been  drop  o p e n e d as p a r t  t h a t t h e e f f e c t s of new  D i v i s i o n of T.B.  situation  setting.  s a n a t o r i u m bed c a p a c i t y was  t h e r a p y began t o r e v e r b e r a t e t h r o u g h  e l e c t i v e surgi-cal cases  The  division  f o l l o w e d s h o r t l y by t h e o p e n i n g  I t i s somewhat i r o n i c  s u r p r i s e d sounding  moved  were b e g i n n i n g t h e t r e k away  an u r b a n  and n a t i o n a l l y ,  so t h a t i n t h e B.C.  unusual  towards  t h e new  education.  i n B.C.  r e o r g a n i z e d and  T u b e r c u l o s i s I n s t i t u t e was  This  sanatorium point,  institutions  t h e B.C.  WCC.  public  government.  14 y e a r p e r i o d between 1952 t o the e r a of complete 26  and  1964  (which  i n t r o d u c t i o n of  British  roughly  chemotherapy  for  T.B.)  1958  the  B.C.  Tranquille  sanatoria  population  Sanatorium  became  centralized  Centre,  Pearson  was  d r o p p e d by  closed  and  tuberculosis  i n the Vancouver area at Hospital  and  the  o v e r 500%.  the  beds  Willow  Essondale  By  Chest  Mental  Health  Facility. As of  the  sanatoria  the D i v i s o n  examination  emptied,  of T.B.  Control.  program  was  remained  one  Operation  Doorstep  i n 1964.  drive  The  d r i v e was  with  great  Even  This  the  became  the  by  increased  facilities  was  latest  (Operation  completed  areas  t h e D i v i s i o n of  1965.  surveyed  under  a  T.B.  were b e i n g c l o s e d  tuberculosis  of or  u n i t s and  specialist  Lower-  possible.  Control  but  enthusiasm).  case-finding  to cardiac  and  in  D o o r s t e p was  the  early  redirected.  rooms a t t h e W i l l o w C h e s t C e n t r e were units  focus  a p r o v i n c i a l X-Ray  t o f i n d as many t u b e r c u l o s i s c a s e s as  the  surgical  full-time  1957,  community p a r t i c i p a t i o n and  tuberculosis  T.B.  of  coordinated  with  - operating  In  started.  Vancouver  Mainland  case-finding  In  1964  converted  i n the  stationed  1960's  from  same y e a r  the  Essondale  was  centralized  in  at  removed f r o m h i s p o s i t i o n . By  the  mid-60's  Vancouver  and  therapy.  Patients  treatment. choice  community  r e l i e d m a i n l y on remained  Hospitalized  f o r the  philosophy  t u b e r c u l o s i s treatment  is  18 t o 24 month d a i l y in  hospital  for  In the D i v i s o n ' s  clearly outlined:  " I t has  less productive  c h a n g e i n t h i s method of c a s e f i n d i n g . "  27  combination  most  drug t h e r a p y remained the  next decade.  surveys are  was  report  of  their  treatment  of  f o r 1971  the  become a p p a r e n t  which w i l l  necessitate  that a  A l t h o u g h many p a t i e n t s  are  treated wholly  require  a  as o u t - p a t i e n t s , i t i s c l e a r t h a t t h e m a j o r i t y 40  period  chemotherapy  in  were  not  tuberculosis control However, shifted  hospital." being  Innovations  rapidly transferred  a  mainly  treatment t o a mainly rifampicin-based introduced replacing innovation  as  course  out-patient  the long-course and  centre  for  the  B.C.  tuberculosis  b a s e d t r e a t m e n t s y s t e m . By 1979 daily  chemotherapy  treatment of choice  methods.  had at  The 1980's saw  t h e a p p l i c a t i o n o f newer r e s e a r c h  the e s t a b l i s h m e n t  to  up i n t h e 1970's a s t h e WCC  in-patient  out-patient  short the  tuberculosis  situation.  t h e p a c e o f change p i c k e d from  in  been  the  even  WCC  bolder  findings  with  o f t h e c o m m u n i t y - b a s e d DCHC.  4.3 THE WILLOW CHEST CENTRE: In  t h e 1960's t h e W i l l o w  on an o u t - p a t i e n t characterized  C h e s t C e n t r e began t o t r e a t more  b a s i s . I n t h e 1970's t r e a t m e n t a t t h e c e n t r e  by a g r o w i n g s h i f t  towards o u t - p a t i e n t  shown i n T a b l e I I I . T A B L E . I l l : P e r c e n t a g e o f T.B. O u t - p a t i e n t s YEAR  and  was as  (1974-80) WCC  55 61 65 68 75 76 78  S o u r c e : The D i v i s i o n o f T u b e r c u l o s i s C o l u m b i a . A n n u a l R e p o r t , 1981. (42)  up  a t WCC.  therapy  % OF CASES TREATED AS OUTPATIENTS AT THE  1974 1975 1976 1977 1978 1979 1980  By  cases  the l a t e  Control, Province  1970's e m p h a s i s was p l a c e d more on p a t i e n t  of B r i t i s h follow  t o e n s u r e d r u g c o m p l i a n c e . A f t e r a n e w - a c t i v e c a s e was l o c a t e d placed  on o u t - p a t i e n t  treatment,  28  a p p o i n t m e n t s were s e t  up  usually every  at  quarterly intervals  2 months) f o r t h e p a t i e n t t o come i n f o r m e d i c a l  to r e c e i v e h i s / h e r drug Until PAS  c o n s i s t e d of a d a i l y course  ethambutol administered  R i f a m p i c i n , ethambutol  or  once  checks and  supply.  1979, t r e a t m e n t  or  for  (but sometimes monthly  f o r 12-24 months.  a n d INH s h o r t - c o u r s e  an a v e r a g e o f 9 months  After  therapy  became t h e s t a n d a r d  o f INH  and 1979,  administered  treatment  at the  WCC. While  t h i s method o f t r e a t m e n t  patients, doubt.  i t ' s usefulness  Increasingly  short-course group  (who  attractive. requested  the  mainly  idea  received  of  therapy  supervised, for the  compliant  in  community-based  'difficult-to-treat'  r e s i d e n t i n t h e Study  Accordingly, and  for  f o r non-compliant p a t i e n t s remained i n  intermittent were  proved f e a s i b l e  Area  )  1980 t h e D i v i s i o n o f T.B.  funding  f o r such  a  project  became Control  from  the  M i n i s t r y of Health. 4.4 THE DOWNTOWN COMMUNITY HEALTH C L I N I C : The  Downtown Community C l i n i c  specifically  to  tackle  T u b e r c u l o s i s P r o g r a m was s e t up  the t u b e r c u l o s i s problem i n the  Study  Area. The (twice  DCHC m a i n l y  intermittent  w e e k l y ) o u t - p a t i e n t d r u g r e g i m e s w h i c h were d e v e l o p e d  developing tubercular  nations.  T h i s may be p a r t i c u l a r l y  population  characteristics bad  uses t h e s u p e r v i s e d s h o r t - c o u r s e  of  the area  of a developing  l i v i n g c o n d i t i o n s ) . T h e DCHC,  which  country's  in  appropriate for the i n some  ways  has  population  (poverty,  therefore represents  the latest  most p r o g r e s s i v e d e v e l o p m e n t s i n t u b e r c u l o s i s c h e m o t h e r a p y . The  main f i n a n c i a l o u t l a y f o r t h e p r o g r a m i s t h e s a l a r y o f t h e 29  T.B.  nurse.  supportive  T.B.  rapport  treatment, patient  The  with  the drugs)  good  supervise  T.B.  nurse a c t u a l l y watches t h e  and go o u t i n t o t h e community t o f i n d appointments.  The t h r u s t o f t h e  r a t h e r than p u n i t i v e and i t s  treatment  combination  of  supervised.  i s daily  Rifampicin,  depending  twice  INH a n d V i t a m i n  i n t h e T.B.  l a s t s 9 months.  generally  or  success  weekly B6.  T h a t i s , p a t i e n t s come t o t h e c l i n i c  medication d i r e c t l y  the  a  may  g r e a t l y on t h e p e r s o n a l i t y o f t h e T.B. n u r s e .  Generally,  (for  to directly  t h e T.B.  when t h e y m i s s c l i n i c  approach i s supportive hinge  i s expected t o e s t a b l i s h  the c l i e n t s ,  ( t h i s means t h a t  injest  patients  nurse  on  Treatment  to receive  nurse's o f f i c e .  Out-patient  using  a is  their  The t r e a t m e n t  treatment duration  t h e amount o f t r e a t m e n t r e c e i v e d a s a n  varies  in-patient  h o s p i t a l i z e d p a t i e n t s ) a n d t h e d e g r e e o f c o m p l i a n c e shown by patient.  Physicians  at  t h e WCC s e l e c t p a t i e n t s f o r a t t e n d a n c e  at the  9 DCHC  program.  criteria  According  are residence  t o Dr.  Chao  at  t h e WCC,  selection  i n t h e a r e a and p o t e n t i a l n o n - c o m p l i a n c e .  T h a t i s , i f s t a f f a t t h e WCC j u d g e a S t u d y A r e a p a t i e n t  i s a non-  complier,  A  person  (even  though  deemed  as  resident at  w i l l p u t h i m / h e r on t h e DCHC p r o g r a m .  p o t e n t i a l l y c o m p l i a n t by t h e WCC s t a f f  i n t h e S t u d y A r e a ) may be p l a c e d  t h e WCC r a t h e r  treat' at  they  t h a n t h e DCHC.  tubercular patients resident  t h e DCHC.  tubercular  The c l i n i c  i s faced  patient case-load  In t h e next c h a p t e r ,  Thus,  on o u t - p a t i e n t t h e most  'difficult-to-  i n t h e S t u d y Ares, ,^re with  one t h e most  therapy  treated  challenging  i n the province.  t h e t u b e r c u l o s i s e p i d e m i o l o g y and 30  socio-  demography of t h e s t u d y a r e a  i s described.  31  CHAPTER 5. THE EPIDEMIOLOGY and SOC10-DEMOGRAPHY of TUBERCULOSIS in  the STUDY AREA.  5.1 INTRODUCTION: The p u r p o s e o f t h i s c h a p t e r i s t o d e s c r i b e t h e m a j o r group  living  i n t h e Study A r e a .  d e s c r i b e d t h e treatment systems  Up t o t h i s  we  have  t h e s e p a t i e n t s have u t i l i z e d  but  i n o r d e r t o comprehend t r e a t m e n t i s s u e s it  i s necessary  describing presently  to describe  high-risk  point  (particularly  the patient  compliance)  population.  Before  t h e h i g h r i s k group t h e epidemiology (as f a r as i s known)  and  socio-demography  of t h e Study  Area a r e  o u t l i n e d as background. 5.2 EPIDEMIOLOGY of T.B. i n the STUDY AREA:  * M e t r o p o l i t a n Vancouver  has h i g h r a t e s of t u b e r c u l o s i s  compared t o t h e p r o v i n c i a l a v e r a g e . " s t u c k " above t h e p r o v i n c i a l a v e r a g e . the  C i t y of Vancouver's  incidence  Metro-Vancouver  rates  appear  Furthermore,  rates  within  N o r t h H e a l t h U n i t and t h e Study Area a r e  sigificantly higher than Metro-Vancouver rates. (Table IV) TABLE I V : C o m p a r i s o n o f I n c i d e n c e R a t e s i n B.C. M e t r o - V a n c o u v e r the North Health Unit, t h e S t u d y A r e a a n d C e n s u s T r a c t 58 (the"Downtown-Eastside") d u r i n g t h e Study P e r i o d . ( 1 9 7 7 - 8 3 ) YEAR 1977 1 978 1979 1980 1981 1982 1983  Rate i n i n B.C. 14.9 16.4 15.0 15.1 14.3 15.2  Rate i n Metro Rate i n Rate i n Rate i n Vancouver N o r t h U n i t S t u d y A r e a T r a c t 58 24.2 22.3 20.0 26.1 27.2 28.8  92.4 63.4 J08.4 H6.9 1 04.2 95.8  186.7 228.9 198.7 (no d a t a ) 252.9 246.9 295.0  199.0 359.0 399.0 (no d a t a ) 399.0 479.0 399.0  •Metropolitan V a n c o u v e r inc'.Ludes the m u n i c l p a .L i t i e s o V a n c o u v e r , R i c h m o n d , N o r t h V a n c o u v e r , West V a n c o u v e r a n d B u r n a b y .  32  P a r t i a l S o u r c e : The D i v i s i o n o f T u b e r c u l o s i s C o n t r o l , P r o v i n c e o f B r i t i s h C o l u m b i a , A n n u a l R e p o r t s 1977-83. ( 4 2 ) When  these  r a t e s a r e averaged out over the Study  Period  the  r e s u l t s a r e i n Table V. TABLE V: Vancouver,  C o m p a r i s o n o f A v e r a g e R a t e s (1977-83) i n B.C. MetroN o r t h H e a l t h U n i t , t h e S t u d y A r e a a n d C e n s u s T r a c t 58.  PLACE  B.C  RATE  15.2  Table  V  Metro-Van Nt. 24.8  U n i t Study Area  97.7  indicates that,  T r a c t 58  248 .4  372.0  f o r t h e time p e r i o d of t h i s  study,  i n c i d e n c e r a t e s w i t h i n t h e S t u d y A r e a were 17 t i m e s g r e a t e r the  provincial  Metropolitan rates  a v e r a g e a n d 10 t i m e s g r e a t e r t h a n t h e  Vancouver.  averaged  Furthermore,  within  r e s t o f t h e S t u d y A r e a , 15 t i m e s t h e M e t r o - V a n c o u v e r  The by  Vancouver.  white  low-income Vancouver  t o those  obtained rates  in  (The r a t e s i n T a b l e s I V a n d V  are  t o the Canadian-born p o p u l a t i o n )  can  i n 1981.  242  not l i m i t e d  Area  r a t e s and 25  s l u m d w e l l e r s was  thousand  u s e r a t e s when c o m p a r i n g  areas  regions.  the  He e s t i m a t e d t h a t t h e n e w - a c t i v e r a t e o f d i s e a s e among  per hundred  larger  58,  than  i n an u n p u b l i s h e d s u r v e y o f t u b e r c u l o s i s  Canadian-born  One  in  rates.  rates obtained i n t h i s study a r e s i m i l a r 21  "Enarson  rates  Census T r a c t  372 p e r 100,000 w h i c h were 50% h i g h e r  times the p r o v i n c i a l  than  to  get a u s e f u l  t h e Study  idea of  rate  Area  with  other  differences  among  However, when a n a l y z i n g v a r i o u s g r o u p s w i t h i n  t h e Study  r a t e s become l e s s m e a n i n g f u l l f o r t h r e e r e a s o n s :  1), the  c e n s u s d a t a f o r t h e S t u d y A r e a i n g e n e r a l and C e n s u s T r a c t particular  58  in  may be i n n a c u r a t e b e c a u s e o f t h e unknown a n d s h i f t i n g  characterisitcs  of the t r a n s i e n t p o p u l a t i o n , 33  2 ) , there  i s no  reliable  estimate  f o r t h e N a t i v e p o p u l a t i o n so t h a t  rates  C a n a d i a n - b o r n N a t i v e s and n o n - N a t i v e s a r e n o t c a l c u l a b l e ; r a t e o f change i n t h e p o p u l a t i o n Between  1961  decreased the  by  and 26%  1976  for  3), the  i s unknown.  the  population  ( s e e s e c t i o n 5.3  in  the  Study  Area  for a detailed discussion  on  socio-demography  was  of t h e a r e a ) . T h i s d e p o p u l a t i o n of s k i d - r o w s 2,6,33 a w e l l documented phenomena i n t h e 1960's and 7 0 ' s . However,  the  1981  1976  p o p u l a t i o n o f t h e S t u d y A r e a was 38  figure  (8538 v s .  7623).  A  12% h i g h e r  14% i n c r e a s e was  than  the  recorded  for  C e n s u s T r a c t 58 f o r t h e same t i m e p e r i o d . T h u s , a t l e a s t o v e r t h e first the  p a r t of the Study P e r i o d , Study  economic  Area.  (It  i s i n t e r e s t i n g that  boom o f t h e 60's and  N o r t h A m e r i c a . T h i s was downturn  population  i s increasing.)  Area  stability High  were 238  and  the  late  70's  C e n s u s T r a c t 58 i n T a b l e  over the Study  mortality  figures.  tuberculosis  across  IV  the  skid-row  then the r a t e s f o r suggest  the  relative  a r e r e f l e c t e d by  F o r t h e d e c a d e 1961-1970 T h e s e were The  death r a t e f o r M e t r o p o l i t a n Vancouver  areas  the  since  Vancouver's  to tuberculosis.  compared t o a p r o v i n c i a l  statistical  during  t o o . B u t , now  t u b e r c u l o s i s deaths i n Metro-Vancouver.  a l l p r o v i n c i a l d e a t h s due  3.5  studies  Period.  i n c i d e n c e r a t e s i n Metro-Vancouver  tuberculosis  was  of  increasing in  show s k i d - r o w e m p t y i n g  these census f i g u r e s are a c c u r a t e ,  Study  of  70's  t r u e i n Vancouver  economic  If  t h e p o p u l a t i o n was  i n B.C.,  r a t e o f 2.7.  Metro-Vancouver's  mean  high there 48.8% annual  i n the decade  For  twenty  rate was 41 t o p p e d o n l y by t h o s e i n t h e C a r i b o o and Skeena d i s t r i c t s . D u r i n g t h e S t u d y P e r i o d , 42.5% (37) o f p r o v i n c i a l d e a t h s due t o 34  death  the  tuberculosis  occurred  tuberculosis  d e a t h r a t e f o r t h e Study Area over t h e Study  was  37.1 w h i c h l i k e  in  epidemiology  influenced  by  Study  Area.  the incidence rate  than the Metro-Vancouver The  the  of  The  i s about  average d e a t h r a t e from T.B.  i n Vancouver  mean  has  been  approximately  10,000 S o u t h E a s t A s i a n i m m i g r a n t s i n t o l o c a l T.B.  (1979-80)  A  comparison  Canadian  (Table  B.C.  the  account 20  for  versus  non-  c o n t r i b u t i o n of the  to the tuberculosis epidemiology i n  the  Canadian-born  Study  Area  of have  high-risk the  area.  V I ) ( I t s h o u l d be p o i n t e d o u t t h a t a c c o r d i n g t o t h e  census, both  influx  i n t h e Study Area and Census T r a c t  58 h e l p s t o d e t e r m i n e t h e r e l a t i v e group  rates,  region.  of t h e p r o p o r t i o n of Canadian-born  born cases o c c u r r i n g  immigrant  the  e p i d e m i o l o g y a n d may  much o f t h e h i g h r a t e s i n t h e M e t r o - V a n c o u v e r  greatly  T.B  since  complicated  higher  tuberculosis.  particularly  also  Recently  Period  10 t i m e s  i m m i g r a t i o n from c o u n t r i e s w i t h h i g h 1970.  annual  and non-Canadian  and Census T r a c t  58  born p o p u l a t i o n were  about  1981 of  equal)  TABLE V I : P e r c e n t a g e o f C a n a d i a n - b o r n a n d n o n - C a n a d i a n b o r n C a s e s in t h e S t u d y A r e a a n d C e n s u s T r a c t 58 d u r i n g t h e S t u d y Period. YEAR  STUDY AREA Can- B o r n non-CanBorn  CENSUS TRACT 58 C a n - B o r n non-CanBorn  1 977 1 978 1 979 1981 1 982 1 983  58 66 58 45 56 78  42 34 42 55 44 22  40 67 67 70 25 100  60 33 33 30 75 000  AVERAGE  60  40  61 .5  38.5  From versus  Table  VI,  non-Canadian  i t i s c l e a r that the proportion born  persons i n both the 35  of  Study  Canadian Area  and  Census T r a c t 58 have r e m a i n e d respectively greater  60% and 40%.  than  usual  r e l a t i v e l y s t a b l e from  The  p r o p o r t i o n s f o r 1983  c o n t r i b u t i o n of  cases  p e r s o n s . W i t h t h i s d a t a base t h e r e i s no way i s an a b e r r a t i o n o r p a r t o f a new of  the Study Area.  non-Canadian  born  approximately higher  1977-1982 a t show a  from  much  Canadian-born  to t e l l  whether  t r e n d i n t h e T.B.  this  epidemiology  Because the p o p u l a t i o n of Canadian-born  and  i n b o t h t h e S t u d y A r e a and C e n s u s T r a c t 58 a r e  equal  these p r o p o r t i o n s suggest  i n the Canadian-born  that  rates  are  p o p u l a t i o n than the non-Canadian  born  in these areas. One if  might  the  segment  expect h i g h e r r a t e s i n the Canadian-born  Native of  the  c o n t r i b u t i o n were h i g h b e c a u s e Canadian-born  population  rates  for  this  be  much  p o p u l a t i o n a r e known t o  h i g h e r than r a t e s f o r non-Native Canadians.  of  the  c o n t r i b u t i o n o f N a t i v e s and n o n - N a t i v e s t o t h e C a n a d i a n - b o r n  case  load  A comparison  of t h e S t u d y A r e a was made t o a s s e s s t h e r e l a t i v e  these  two  groups  on  Candadian-born  rates.  impact of  (Table  VII)  TABLE V I I : P e r c e n t a g e o f N a t i v e s and n o n - N a t i v e s Among C a n a d i a n b o r n c a s e s i n t h e S t u d y A r e a and C e n s u s T r a c t 58. YEAR  STUDY AREA Nat i v e non-Nat i v e  CENSUS TRACT 58 Nat i v e non-Nat i v e  1977 1978 1979 1981 1982 1983  44 28 47 37 35 45  56 72 53 63 65 55  50 50 50 43 67 40  50 50 50 57 33 60  AVE.  40  60  50  50  Like  Table  VI,  Table  V I I shows  relative  stability  p r o p o r t i o n o f c a s e s d i s t r i b u t e d between t h e two g r o u p s . 36  in  the  However,  unlike  the comparison  of Canadian-born  w i t h non-Canadian-born  in  T a b l e V I , t h e r e a r e d i f f e r e n c e s between t h e S t u d y A r e a and  Census  Tract  Native  58.  C e n s u s T r a c t 58 has a 10% h i g h e r p r o p o r t i o n o f  cases than the Study Area Table  VII also indicates that  arising were  i n the Canadian-born  non-Natives.  persons  in general.  This  f o r t h e S t u d y A r e a 60% o f  p o p u l a t i o n d u r i n g the Study  means  high rates  among  i n the Study Area r e c e i v e a s i g n i f i c a n t  non-Native  Study Area?  Firstly,  r i s k groups  f o r T.B.  Secondly,  has  the  were  due  e p i d e m i o l o g y of  i n the a r e a :  results  1) U r b a n N a t i v e s ,  3) N o n - N a t i v e s  born  show a s t a b i l i t y  2)  the  highpersons  i n Canada.  the p r o p o r t i o n of c a s e s w i t h i n each of the t h r e e  groups  in relation  f a i r l y c o n s t a n t o v e r t h e S t u d y P e r i o d 'as have 1977  i s an e x c e p t i o n .  For  this  year,  rates.  rates  were  low compared t o t h e o t h e r f i v e y e a r s u n d e r s t u d y . I t i s  n o t known why Thirdly,  from  time.  year  unusually  contribution  to  remained  (The  Canadian-born  t h e y show t h a t t h e r e a r e t h r e e main  b o r n o u t s i d e of C a n a d a , and  is,  Period  Canadians.  What do t h e s e r e s u l t s mean i n t e r m s o f T.B.  That  cases  t h e r a t e s were l o w e r i n 1977.)  approximately to  Canadian-born  40% o f c a s e s d u r i n g t h e  Study  Period  people  born  o u t s i d e o f Canada  and  60%  persons.  The  Native contribution  to  Canadian-born  cases  was  about  40% so t h a t 60% o f C a n a d i a n - b o r n  Study  A r e a were n o n - N a t i v e s .  over  the study p e r i o d ,  year  was  except  based  in  These p r o p o r t i o n s remained f o r the year  1983.  an anomaly o r t h e b e g i n n i n g o f a new  and u n d e t e r m i n a b l e  cases  due  on t h e d a t a i n t h i s  37  study.  the  stable  Whether  trend i s  to  this  unknown  5.3  SOCIO-DEMOGRAPHY OF THE STUDY AREA:  The  p r e v i o u s s e c t i o n has shown t h a t t u b e r c u l o s i s  within terms  of  the  t h r e e main h i g h - r i s k g r o u p s  in  the  i n g e n e r a l terms the  T.B.  in  area.  This  socio-demography  the Study Area. A  report  (these  3  prepared 1978  on t h e h e a l t h s t a t u s of c e n s u s t r a c t s census t r a c t s c o i n c i d e e x a c t l y with  for  of  of p e o p l e l i v i n g  1961  and 1976  p e o p l e o u t of t h e a r e a . 1981 age  Area)  Departments  socio-demographic are  f e d e r a l census  based  report.) by  i n d i c a t i n g a f a i r l y s t e a d y movement  of  ( T h i s t r e n d was  r e v e r s e d between  i n c r e a s e d by  t o a Vancouver  f i g u r e o f 14%.  E a s t s i d e a r e a t h i s f i g u r e was p a r t i c u l a r l y  1976  and  12%) I n t e r m s  of  I n t h e Downtown-  pronounced at  36%.  In V a n c o u v e r t h e r e i s an a p p r o x i m a t e l y e q u a l r a t i o o f m a l e s However,  for  male and 3 1 % f e m a l e . Vancouver  is  Eastside  where  In  of  terms  population British-born  in  27% o f s t u d y a r e a r e s i d e n t s were 65 y e a r s of age  o l d e r compared  females.  59  i n t h e s t u d y a r e a had d r o p p e d  as t h e Study Area p o p u l a t i o n structure,  and  Study  (The d a t a f r o m t h i s r e p o r t  1976 u p d a t e o f t h e 1971  number  26% between  socio-economic 3  residents.  m a i n l y on t h e The  the  57,58,and  the  t h e V a n c o u v e r H e a l t h and P l a n n i n g  highlights  situation  or  problem  t h e S t u d y A r e a and o u t l i n e s t h e e p i d e m i o l o g y o f  section attempts to explain of  is a  t h e s t u d y a r e a 69% of t h e p o p u l a t i o n  This difference  even more p r o n o u n c e d males  ethnic  compared  represent  i n r e l a t i o n t o the r e s t  i n c o n s i d e r i n g the 85%  of  the  g r o u p s t h e S t u d y A r e a has to  population  7% a s a whole compared 38  a  i n Vancouver  t o 53% i n  the  and is of  Downtownpopulation.  37% and city.  Chinese a It  32% is  difficult in  the  t o o b t a i n an e x a c t a c c o u n t i n g o f t h e n a t i v e area.  transients.  This  area  also  contains  a  large  population number  E s t i m a t e s o f t h i s p o p u l a t i o n a r e 3,000 o f w h i c h  of half  are probably n a t i v e . Education,  income and employment l e v e l s a r e low  c i t y a v e r a g e s . The  unemployment r a t e i n t h e Downtown d i s t r i c t s i s  4 1 % c o m p a r e d t o 11% i n V a n c o u v e r population  had  in Vancouver.  compared t o  incomes  and a l m o s t 70% o f t h e s t u d y a r e a  l e s s t h a n $3,000 p e r y e a r c o m p a r e d t o 36%  F o r e d u c a t i o n , 62% o f s t u d y a r e a r e s i d e n t s had  only  e l e m e n t a r y s c h o o l e d u c a t i o n compared t o 33% i n V a n c o u v e r . These socio-economic c o n d i t i o n s a r e a s s o c i a t e d w i t h g e n e r a l health  i n the Study Area p o p u l a t i o n .  h i g h r a t e s o f a l c o h o l and d r u g abuse h i g h r a t e s of c i r r h o s i s of the In 1977 of  the Study Area  partially  reflected  some f a c t s a r e h i g h l i g h t e d . F o r e x a m p l e ,  respective be  figures  o f 8%  borne  i n mind  (However,  i t  residents  i n t h e S t u d y A r e a may  difference  should  22% o f male and  and  5%  that  in  disease  Vancouver.  greater  age  of The  i n d e a t h r a t e s from r e s p i r a t o r y d i s e a s e c o m p r i s e  the  and V a n c o u v e r .  disease  in  the  average.  ( A g a i n , age  be a c o n t r i b u t i n g  23%  factor.)  single biggest difference Area  very  i n the year  female d e a t h s i n the Study Area a r e from r e s p i r a t o r y to  in  has  liver.  l o o k i n g a t c a u s e s o f d e a t h by a r e a i n V a n c o u v e r  compared  i n m o r t a l i t y p a t t e r n s between t h e S t u d y  Effectively,  d e a t h r a t e s from  S t u d y A r e a a r e 350% h i g h e r t h a n  respiratory  the  Vancouver  s t a n d a r d i z a t i o n w o u l d have t o be c v a r i e d  on t h e d e a t h r a t e s t o r e f l e c t  the true  I n summary t h e r e p o r t s t a t e d : in  Thus,  ill  comparison to Vancouver,  "The  out  difference).  S t u d y A r e a may  be  described,  as an a r e a w i t h a d e c r e a s i n g number 39  of  r e s i d e n t s . I n c o m p a r i s o n t o V a n c o u v e r i t has  of o l d e r higher  s i n g l e males,  a high  l o w e r l e v e l s of e d u c a t i o n  l e v e l s of unemployment.  and  proportion income  I t i s e t h n i c a l l y a more  and  diverse 3  a r e a t h a n V a n c o u v e r and It  must  be  population row In  a high proportion  re-emphasized  t h a t between  of t h e S t u d y A r e a i n c r e a s e d  depopulation the p r e v i o u s  the  has  trend section  S t u d y A r e a and  region.  the  of  ethnically diverse Because  the  proportion  the  i t was  In t h i s  the  study area i s  than the  high-risk  However,  for  this  e p i d e m i o l o g y of The  poverty,  are a r i s k Older  the  area.  and  older,  poorer  the  older population  only  in  factor  and  the  endogenous e x a c e r b a t i o n this  i n mind,  i n the  of  produce  Area.  in  T.B.  residents  tuberculosis. higher  Vancouver.  reactivation Any  increase  the  in  factors risk  of  groups.  developments i n the 40  large  Study  Study Area.  f o r the h i g h - r i s k recent  more  a  operating  r i s k of  w h i c h make t h e s e l i v i n g c o n d i t i o n s worse may  With  and  m a l n o u r i s h e d run a  a greater  d i f f i c u l t living conditions  that  d i s t r i c t s i n Vancouver. Groups  a l c o h o l i c and  run  the  population.  endogenous e x a c e r b a t i o n  i m m i g r a n t s may  in  in  been shown  p o o r l i v i n g c o n d i t i o n s o f most a r e a  are  skid70's.  the Area i t s e l f i s l i k e l y to  be  f a c t o r i n the  and  the  the h i g h e s t  i t has  are concentrated  not  the  early  o f r e a c t i v a t i o n t h a n o l d e r w e l l - o f f r e s i d e n t s of  Natives the  T.B.  may  r e s i d e n t s who  risk  and  r e s t of V a n c o u v e r ' s  immigrants,  1981  reversing  60's  section  more t u b e r c u l o s i s c a s e s t h a n o t h e r at  12%  and  shown t h a t t u b e r c u l o s i s r a t e s  S t u d y A r e a h o u s e s an  of  1976  the Downtown-Eastside are  Metro-Vancouver population  of  by  of t r a n s i e n t s . "  Study Area  in  relation  to  Vancouver's  tuberculosis related  e p i d e m i o l o g y of t h e  to  Expo-86  demographic patients which  living  i n the  1986, up  by  600%  According twenty  depopulating  and  of the  Study A r e a .  Many o f  Study Area l i v e  conducted  during  A  at  least  1986  300  t r e n d has  i n a s t a t e of A  portion  high-risk  to  likely to  downtown  about  downtown r e s i d e n t s 44  area  Social  1,000  will  Planning, planning  rooms  survey will  Presently have  Clearly,  been the  be  Jessup  (February dislocated  future  Study Area i s u n c e r t a i n  tubercular  tuberculosis  as  socio-  the  has  population been  m a j o r p r o b l e m s emerge.  which  and  area  living  the p o p u l a t i o n in  these  have enough s o c i a l  l a r g e e f f l u x of p e o p l e i n v o l v e d  bring considerable  exacerbation  from  flux.  cope w i t h the  evictees  are  February  Association  worsen.  C i t y o f V a n c o u v e r d o e s not  e v i c t i o n s two  in  C i t y h o u s i n g p l a n n e r John  just started."  of t h e  to  Because the units  i n f l u x expected  Residents  situation will  demographic s t r u c t u r e of the is  the  predicted  renovations.  the  hotels  Many of t h e s e h o t e l s  tourist  in  the  tubercular  run-down  t h e V a n c o u v e r Sun  Downtown E a s t s i d e  the  the  D o w n t o w n - E a s t s i d e ' s 26 h o t e l s a r e  i n February by  and:"The  rents 48  developments changing  in f a i r l y  the  Expo-86.  the  predicted  1986)  t o a s u r v e y by hotel  of  renovations.  also  the  affect  Property  t o V a n c o u v e r s ' d e p u t y d i r e c t o r of  two  affected  area.  i n t o p e r m a n e n t homes.  According average  ( E x p o - 8 6 ) may  are  r e n o v a t e d t o c a p i t a l i z e on  Expo-86.  go  character  often turn  being  World-Fair  personal  may  of t h e d i s e a s e .  increase  Firstly, hardship the  S e c o n d l y , the 41  the  and  rate  at  hotels. housing in  the  evictions  will  financial of  e v i c t i o n s may  stress  endogenous increase  the  tuberculosis  population  rates  in  the area  Obvious  problems a r e l i k e l y  case-holding  tuberculosis likely  a  of i n f e c t e d people i s e s s e n t i a l l y  street to mingle with the uninfected  and  as  i n the area.  patients  settled  pushed out onto  the  population.  i n terms of t u b e r c u l o s i s I t may be h a r d e r  among t h e e v i c t e e s .  cause d i f f i c u l t i e s  formerly  t o keep t r a c k  The  f o r t h e DCHC's T.B.  treatment  evictions  of will  nurse i n terms of  c a s e - f i n d i n g and c a s e - h o l d i n g . I n summary, t h e S t u d y A r e a i s a d e p r e s s e d a r e a h o u s i n g population area  of mainly  forcing  tuberculosis The  o l d e r male r e s i d e n t s . Many r e s i d e n t s o f  a r e a l c o h o l i c and on w e l f a r e .  area  risk  disease spread  a  formerly  (or already  settled  group  with the disease)  t h i s group i s l i k e l y  the  Rents a r e i n c r e a s i n g i n the at  high-risk  out of t h e i r  f o r i n c r e a s e d r a t e s o f endogenous e x a c e r b a t i o n among  a unique  for homes.  of  the  i n c r e a s e d as i s t h e r i s k  of  of t u b e r c u l o s i s t o t h e u n i n f e c t e d p o p u l a t i o n  i n the  area.  5.4 THE HIGH RISK GROUP: We have d e s c r i b e d T.B. e p i d e m i o l o g y Study Area. present The  and s o c i o - d e m o g r a p h y i n t h e  From t h i s d i s c u s s i o n i t i s c l e a r t h a t h i g h  i n t h e a r e a and t h e a r e a  i s a poor d i s t r i c t  purpose of t h i s s e c t i o n i s t o d e s c r i b e  rates are  of Vancouver.  i n greater d e t a i l the  high r i s k group i n the d i s t r i c t . As b a c k g r o u n d t h e a u t h o r high-risk  groups  Information  i n other  attempted f i n d urban a r e a s of  i n f o r m a t i o n on developed  was s p a r s e . What f o l l o w s i s a r e v i e w  similar  countries.  of the a v a i l a b l e  literature. A study  by Chapman and D y e r l y  i n t h e e a r l y 1960's i n t h e U n i t e d  42  States  reported  that crowding,  e x p o s u r e were i m p o r t a n t with  s e v e r i t y of d i s e a s e  In and  i n the  a  1950  t h e most i m p o r t a n t  n o n - w h i t e s had  i n f e c t i o n t h a n w h i t e s and b o t h w h i t e s and  high  deprived  and  T.B.,  b r o k e n homes.  a  among  urban  recent  associated  with  education,  divorce  A the  i n the U n i t e d  non-white r a c i a l or s e p a r a t i o n  1973  s u r v e y of employees  New  York  infection  and  sex,  of t h e s e s t u d i e s a r e  socio-demographic fairly  in that  and  higher lower  with 32  is associated  were  income,  less 23  analysis) "  race,  surprise regions: Three  t h a t T.B. like main  demography and  in  tuberculosis socio-economic  order." u s e f u l b e c a u s e t h e y show c l e a r l y  socio-economic  i n d i c a t o r s are  B e c a u s e t h e s e s t u d i e s show t h a t  with poverty,  rates  rates  low  is likely  education, located  e t c . i t may  that  associated  p r e d i c t a b l y w i t h t u b e r c u l o s i s among u r b a n p o p u l a t i o n s  developed country.  to  residences.  (using m u l t i v a r i a t e that  found  economically  reactor  more c r o w d e d  E d u c a t i o n Department found  Kummerer  exposure  tuberculin  status,  and  Alabama  and  with  household  States,  i s significantly associated  s t a t u s , age All  of  T.B.  tuberculosis  Comstock and  reactivity associated  (1977)  of  in  s t u d e n t s i n W a s h i n g t o n D.C.  paper  adults  transmission 10 factor.  of  r a t e s t h a n women i n f o r  i n 1963,  crowded l i v i n g c o n d i t i o n s , 29  more  intensity  r a t e s of  greater  non-whites. L a t e r ,  r a t e s of t u b e r c u l i n  In  had  and  urban p o p u l a t i o n  much g r e a t e r  men 12  urban h i g h - s c h o o l  and  intrafamilial  s t u d y by Comstock of an  Georgia,  studied  mode of l i v i n g  in a  tuberculosis come as  i n t h e most d e p r i v e d  no  urban  skid-row. s t u d i e s were f o u n d d e s c r i b i n g facets of socio43 e p i d e m i o l o g y of s k i d - r o w t u b e r c u l o s i s p a t i e n t s . I n  a  1960 s t u d y  i n New Y o r k C i t y ,  were X - r a y e d .  9,000 h o m e l e s s s k i d - r o w r e s i d e n t s  A t o t a l o f 144 c a s e s o f n e w - a c t i v e  c a s e s were  found  1 1  among t h e X - r a y e d A  g r o u p g i v i n g a r a t e o f 1600 p e r 100,000.  1969 s u r v e y o f a B a l t i m o r e c h e s t c l i n i c  row  population  urban to  of the c l i n i c  non-white  skid-  65:35 f o r  and w h i t e s .  a t t e n d e e s were n o n - w h i t e 23  a r e a was 4 3 % n o n - w h i t e .  non-white  to a  found a sex and race d i s t r i b u t i o n of  r e s p e c t i v e l y men a n d women a n d n o n - w h i t e s percent  catering  Sixty-five  even  though  (Note, i n our Study Area  the  the white  r a t i o was 50:50 a p p r o x i m a t e l y w h i l e t h e w h i t e  to  r a t i o a t t h e DCHC was a b o u t 60:30.  Finally,  a  1971  Danish  study based  on t h e n a t i o n a l  Danish  tuberculosis case r e g i s t r y f o r t h e y e a r s 1960-68 a t t e m p t e d t o d e f i n e t h e m a j o r h i g h - r i s k g r o u p s i n Denmark i n s o c i o - d e m o g r a p h i c 26 terms.  This  forty  s t u d y showed t h a t i n Copenhagen d i v o r c e d men  years  o f age h a d r a t e s w h i c h were a p p r o x i m a t e l y  100,000 p l a c i n g them i n a d e f i n i t e h i g h - r i s k g r o u p . t h e s t u d y d e f i n e d an u r b a n of  40  and  Although the  69 who were  this  adult  tuberculosis  Furthermore,  g r o u p o f " l o n e l y men" between t h e a g e s either  single,  population  cases.  For  they  this  divorced  status  may  be  an  contributed  group  t u b e r c u l o s i s was 160 p e r 100,000. marital  200 p e r  or  widowed.  g r o u p o f u r b a n i z e d " l o n e l y men" c o m p r i s e d male  over  the  33%  incidence  11% o f of  the  rate f o r  The s t u d y c o n c l u d e d by s t a t i n g  important  risk  factor associated  with tuberculosis incidence. Based developed  on  these  studies i t i sclear  countries) at high risk  d i s p r o p o r t i o n a t e number o f m a l e , 44  that  f o r T.B. non-white,  urban  groups ( i n  tend t o c o n s i s t of a single,  people of  low s o c i o - e c o n o m i c When  the  analysed  Vancouver  group  gathered f o r a l l the cases i n t h i s  according  indicators  From  data  status.  this  to  basic  socio-demographic pattern  i s clearly  skid-row tubercular population.  t h i s t a b l e a socio-demographic with  tuberculosis living  Where p o s s i b l e ,  the proportion  demography o f t h e S t u d y A r e a  and  study  socio-economic  observable  (See T a b l e  p r o f i l e of  f o r the  VIII)  the  high-risk  i n t h e S t u d y A r e a c a n be o f T.B.  are  cases r e l a t i v e  drawn.  to socio-  i s compared.  TABLE V I I I . S o c i o - d e m o g r a p h i c d i s t r i b u t i o n o f S t u d y A r e a T.B. C a s e s R e g i s t e r e d i n t h e y e a r s 1977-79 & 1981-83. (234 C a s e s ) Variable  Catagory  RACE  White Nat i v e Chinese  54 24 22  37  SEX  Male Female  78 22  66 34  AGE  20-59 60 +  64 36  53 36  MARITAL STATUS  Married Single Wid & D i v .  23 48 29  ALCOHOLIC  Yes No  72 28  OCCUPATION  Employed Unemployed Retired  20 62 18  41  63 37  49 51  BIRTHPL.  Table  of  Canada Not Canada  VIII  population,  inr'lc a t e s  a greater  Canadian-born  20-59  T.B CASE %  that  compared  proportion  and a g r e a t e r  % i n Study  to  of males,  proportion  Study  a greater of those i n  a r e found i n the t u b e r c u l a r p o p u l a t i o n 45  the  Area  Area  proportion age-group  of t h e Study  Area.  This  may  indicate  Vancouver,  men,  are at greater these  data  inability the  this  risk  20-59 and  than the average p o p u l a t i o n may  for  high-risk  occur because  transient  Canadian-born  f o r T.B.  However, of  t h i s a r e a p a r t i c u l a r l y as i t r e l a t e s  to i t ' s  (And p a r t i c u l a r l y  i s high  Canadian-born.)  compared t o t h e r e s t o f B.C.  a gradient  Moreover,  endemic i n t h e S t u d y A r e a and may  risk  and t h a t  a s we go f r o m t h e N o r t h H e a l t h  t o the Downtown-Eastside.  are  between t h e a g e s  as  In summary, C h a p t e r 5 shows t h a t t u b e r c u l o s i s i n c i d e n c e  Area  is likely  the  20-59,  in  population  of  of  i n Vancouver  Unit  rates to  the  conditions  contribute  increase Study  of  to  poverty  heightened  f o r endogenous r e a c t i v a t i o n f o r the h i g h - r i s k groups  * t h e r e . The that  Study Area p o p u l a t i o n  increases  increased  i n r a t e s n o t e d f o r t h e S t u d y P e r i o d may  of  this population  relatively  s t a b l e throughout the Study P e r i o d  Recent development particular  local  leading  also increase  uninfected  population  because  of  then  be  rates  were  i n the Study A r e a .  the  area.  residents  be The  r a t e of r e a c t i v a t i o n . The  the r i s k of p r i m a r y i n f e c t i o n as  a  weaken t h e r e s i s t a n c e o f t h e  to a higher  population  hotel  I f so,  of e v i c t i o n s i n  w i t h e v i c t i o n s may  infected population e v i c t i o n s may  shift.  1981,  i n t h e S t u d y A r e a r e l a t e d t o Expo-86 may  concern  stress associated  living  between 1976 and  reflection  of  area  of the i n n a c c u r a c y  t o count the t r a n s i e n t p o p u l a t i o n .  male and  so  even w i t h i n  p e o p l e between t h e ages  differences  census  that  a  hitherto  i s mobilized  to  fairly find  f o r the settled  alternate  accomodation. Canadian-born  p e r s o n s c o n t r i b u t e a b o u t 60% o f t h e c a s e s i n  46  the  Study  Area.  versus it  In  e s t i m a t i n g the r e l a t i v e c o n t r i b u t i o n of  non-Native cases to the h i g h Canadian-born  i s clear  Native  that non-Native cases occur  cases.  1.5  contribution,  t i m e s as  often  T h i s i s an u n u s u a l r a t i o b e c a u s e b a s e d on  provincial  r a t e s f o r N a t i v e and n o n - N a t i v e C a n a d i a n - b o r n  we  expect  would  N a t i v e s and n o n - N a t i v e s .  110/100,000 f o r N a t i v e s and Rates  ( T h i s i s b a s e d on a  find  members o f t h e s e two g r o u p s c o n t r i b u t i n g t o t h e  Native  low  Canadian  17  rate  of  9.7/100,000 f o r n o n - N a t i v e s )  countries with high rates.  generally  least  B.C.  from  are  average  an e q u a l p o p u l a t i o n  have been h i s t o r i c a l l y h i g h f o r N a t i v e s and  l o a d i n the Study Area.  as  persons  t h e number of N a t i v e c a s e s t o be a t  t i m e s t h e number o f n o n - N a t i v e c a s e s a s s u m i n g of  Native  Thus,  However,  i t i s not s u r p r i s i n g  rates f o r non-Native  ( a b o u t 10/100,000 i n B . C . ) . h i g h - r i s k group  immigrants  T.B.  case  Canadians  Clearly,  i n the Study Area i s  to  the a  non-  unique  group. Although  studies  o f T.B.  epidemiology i n skid-row  d e v e l o p e d c o u n t r i e s a r e few and and this  'down-and-out' This  Canadian-born  major  in  s t u d i e s i n Denmark,  t h e U n i t e d S t a t e s have c l e a r l y p o i n t e d o u t t h e e x i s t e n c e  disease.  group  f a r between,  areas  has  local-born  study  shows  group the  persons i n Vancouver.  significant  North American  47  high-risk  contribution I t i s highly  i m p a c t t o t h e T.B.  cities.  at  of likely  epidemiology  for  of the  non-Native that  this  of  most  6:  CHAPTER  COMPLIANCE 6.1  COMPLIANCE AND SOCIO-DEMOGRAPHY:  The the  data i n Table V I I I Study Area.  Prior  of t h i s t u b e r c u l a r However,  since  selected within  who  at  t h e DCHC.  differentiate Study  Area.  has  of  feel are  skid-row  o f t h e DCHC most members  t h e DCHC,  clinicians  the d i f f i c u l t - t o - t r e a t  tubercular  population  I t i sclear  that t h i s group of  certain  for  socio-demographic  i t f r o m t h e main body o f t u b e r c u l a r  _ l  socio-  RACE White Nat i v e Chinese Other BIRTHPLACE Canada China S.E. A s i a Europe Unknown ALCOHOLIC No Yes Unknown  sub-group out-patient perceived  features patients  TABLE I X . S o c i o - d e m o g r a p h i c s o f WCC a n d DCHC p a t i e n t s  SEX Male Female  have  which i n the  (Table IX)  DEMOGRAPHY  WCC #  C CL LI IN NI IC C  %  in  w o u l d have been t r e a t e d a t t h e WCC.  establishment  they  non-compliers  t o establishment  population  this  therapy  show who i s d i a g n o s e d a s t u b e r c u l a r  DCHC #  19 12  61 39  66 10  87 13  10 2 15 4  32 7 48 13  44 25 7  58 33 9  9 5 13 4  29 16 42 13  58 6 1 9 2  76 8 1 12 3  19 4 8  61 13 26  15 56 5  20 74 6  48  (81-83)  Table  IX  shows t h a t compared t o t h e WCC t h e DCHC  greater  proportion  of  natives  (33% vs 7%),  Canadian-born  alcoholics  p r o p o r t i o n of males (87% vs 6 1 % ) . DCHC  patients  and  a  greater  compared t o t h e WCC t h e  t r e a t s a s m a l l e r p r o p o r t i o n o f C h i n e s e a n d S.E.  patients  a  (76% vs 2 9 % ) ,  (74% vs 13%) , Also,  treats;  A s i a n born  (9% vs 58%).  These  data  show  that the best p e r c e i v e d  compliers  i n the  tubercular  p o p u l a t i o n of t h e Study Area belong t o t h e Chinese o r  South-East  Asian  particularly  born  Natives,  group.  The  Canadian-born  a r e p e r c e i v e d a s t h e most  population, non-compliant  group. The  point of t h i s data a n a l y s i s  selected  into  compliance Control.  t h e DCHC p r o g r a m on t h e b a s i s o f  as  judged  According  hospitalized  i s t o show t h a t p a t i e n t s  or  by to  their  probable  c l i n i c i a n s at the Division 22  Dr.  Enarson,  not and h i s / h e r l e n g t h  whether of  a  of  is  hospitalization  is  r e l a t e d t o perceived c o m p l i a b i l i t y of the p a t i e n t .  both  in-patient  determined  in  out-patient  T.B.  patient  often  and  are  treatment  modalities  l a r g e p a r t by m e d i c a l p e r c e p t i o n s  of  Thus, are  individual  compliability. Clinicians patients  or  may  use  socio-demographic  t h e y may u s e some o t h e r c r i t e r i a .  patients into a 'difficult-to-treat' demographics then c l i n i c a l  non-compliant  b a s i s , t h e end r e s u l t groups.  If  to  select  they  select  g r o u p on t h e b a s i s o f s o c i o -  experience i s t e l l i n g  demography a n d c o m p l i a n c e a r e l i n k e d . perceived  criteria  them t h a t  socio-  Even i f t h e y s e l e c t  their  g r o u p on an o t h e r - t h a n  socio-demographic  i s socio-demographically different complier  T h u s , s o c i o - d e m o g r a p h i c s a r e somehow l i n k e d t o p e r c e i v e d 49  compliance performance study  data  may  of t u b e r c u l o s i s o u t - p a t i e n t s .  show  a  c o m p l i a n c e - what about The  link  between  While  the  socio-demography  and  the l i t e r a t u r e ?  l i t e r a t u r e on c o m p l i a n c e  i s extensive.  From t h i s body o f  literature  a n d h i s own r e s e a r c h B e c k e r d e v e l o p e d 5  compliance.  ( F i g 2)  a  model  of  FIGURE 2: HEALTH B E L I E F MODEL P e r c e p t i o n about h e a l t h  Modifying  I Motivation  P e r c e i v e d Value of Illness threat reduction P e r c e p t i o n o f how w e l l compliance w i l l reduce illness The  Compliant  Behavior  I I L i k l i h o o d of  I  Demographic Structural Psychological  compliance t o the drug regime.  readiness  undertake  threat model  states  that  behaviour  depends  compliant  behaviour w i l l  factors about  factors  on  motivation  to  and b e l i e f  reduce t h e i l l n e s s .  a r e seen a s m o d i f y i n g components  h e a l t h which  This  model  literature  compliant  i n how  well  the  Socio-demographic  affecting  perceptions  i n turn determine the l i k l i h o o d of compliance.  i s w i d e l y accepted and quoted  and p r o v i d e s  some  theoretical  i n the  compliance  rationale  linking  compliance and socio-demography. 6.2 ATTENDANCE COMPLIANCE: T h e r e a r e two t y p e s o f c o m p l i a n c e d i s c u s s e d i n t h e l i t e r a t u r e : 31 attendance  and  concerned  entirely  treatment  treatment compliance. with  attendance  Attendance compliance to  appointments  compliance t a c k l e s t h e i s s u e of p a t i e n t adherence  is  while toa  recommended p r o g r a m o f t r e a t m e n t . In for  t h i s study,  t h e f o c u s i s m a i n l y on a t t e n d a n c e  compliance  two r e a s o n s : 1) A t t e n d a n c e c o m p l i a n c e measurement i s one t h a t 50  has  relatively  treatment  compliance drugs While  clinic In  to  a clinic  which  For  treatment injestion  i s easier  to  r e v e a l a s much A l l that  measure  about  of  in  Control  than  treatment  i s b e i n g measured successful,  is the  on a t t e n d a n c e c o m p l i a n c e a s  i s the  minimum  ( I f t h e p a t i e n t won't come t o  clinic  i n existence,  alcoholics  and  is  the  treatment  although  determining  the  of  clinic  be  a  i t ' s high patients,  socio-demographic  t o treatment  i t i s clear that c l i n i c i a n s at the select  for  important.  primacy  compliance  made  i s the  will  'difficult-to-treat'  i s particularly  the  prerequisite  t h e p o p u l a t i o n i n t h e Study Area w i t h  summary,  is  as  t o p i c k - u p m e d i c a t i o n s t h e n even i f t h e c l i n i c  interpretation T.B.  attendance  attendance  variables  same  (such as t h i s study) t h e assumption  outcome.  proportion ensuring  the  is  well.  variable  tuberculosis  failure.)  is  of  where t r e a t m e n t  F o r o u t c o m e s t o be  e v a l u a t i o n based  regular  regularly  In  i t doesn't  the c l i n i c .  must f u n c t i o n  successful  best  compliance  as treatment compliance.  dependent that  compliance  measurement  monitored).  compliance  attendance  with  ( b e c a u s e when a p a t i e n t a t t e n d s t h e c l i n i c  attendance  treatment  compared  and 2) f o r t h e DCHC,  attendance  i sdirectly  outcome  problems  compliance;  supervised,  of  few  o u t a g r o u p t h e y deem  socio-demographically different  as  i s open  to  Division  of  'non-compliant'  from t h e r e s t  Study Area p o p u l a t i o n . A n a l y s i n g c o m p l i a n c e  of  the  in relation  to socio-  d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h i s p o p u l a t i o n may h e l p  determine  the e f f e c t i v e n e s s of the o u t - p a t i e n t c l i n i c .  51  The d e p e n d e n t because  it  is  variable  for this  study  i s attendance compliance  m e a s u r e a b l e and b e c a u s e e n s u r i n g  attendance i s a p r e r e q u i s i t e  for clinic  52  success.  regular  clinic  CHAPTER 7 . THE EFFECT OF TWO TYPES OF CLINIC SYSTEMS ON COMPLIANCE TO TUBERCULOSIS CHEMOTHERAPY METHODS 7.1  OVERVIEW:  The the  study design i s d i v i d e d  three questions posed  'drop-outs' Part  i n t o four p a r t s .  i n t h i s t h e s i s and part 4 analyses the  from the DCHC.  1  i s the e v a l u a t i v e component of the t h e s i s .  retrospective  matched  case-control  study  hypothesis that the rate of compliance DCHC  equals  attended group  P a r t s 1-3 answer  the  rate of compliance  the WCC.  which  to  test  It  is a  the  null  f o r p a t i e n t s a t t e n d i n g the f o r matched  controls  For t h i s s e c t i o n the c o n t r o l group  who  i s the  attended the WCC i n the three year p e r i o d p r i o r  to  establishment of the DCHC and the experimental group i s the group which  attended  the DCHC i n the three year  period  after i t ' s  establishment. Part  1 i s concerned with a matched comparison  patients  over  two  time  periods.  Parts 2 and  of WCC and 3  are  DCHC  focused  e n t i r e l y on the DCHC. Part 2 determines p r e d i c t compliance In the  Part 3  a  v a r i a b l e s best e x p l a i n and  f o r p a t i e n t s t r e a t e d at the DCHC.  the sociodemographic  4 compliance  coxr-parison  which independent  and treatment  variables for  q u a r t i l e s at the DCHC are compared.  sociodemographic  and treatment p r o f i l e  From  this  for least  versus most compliant p a t i e n t s i s developed. In  Part 4  the number and c h a r a c t e r i s t i c s of 'drop-outs'  the DCHC program are analyzed.  The preceeding a n a l y s i s i n  from terms  of  a t t e n d a n c e c o m p l i a n c e g i v e s us no i n f o r m a t i o n on t h e d r o p - o u t  rate  from t h e DCHC. P a r t 4 a t t e m p t s t o f i l l  With t h i s methodology the  WCC i s d e t e r m i n e d ;  the  DCHC  t h a t gap.  t h e DCHC's e f f e c t i v e n e s s major  a r e determined;  f a c t o r s p r e d i c t i n g compliance  and, a p r o f i l e  c o m p l i a n t and non-compliant  i n relation to  i s developed  at for  patients.  7.2 SAMPLE: 1. Sample The  Selection: patients  in this  t u b e r c u l o s i s cases  resident  study  were  a l l the  i n census t r a c t s 57,  t i m e o f d i a g n o s i s i n t h e y e a r s 1977, 78, Because of  there i sa legal  tuberculosis  79,  81,  o f T.B.  Control,  i n t h e a r e a a r e on r e c o r d w i t h t h e D i v i s i o n .  found  u s i n g a master  was  within  list  of Vancouver  patients.  at  82 a n d 1983.  requirement t o r e g i s t e r a l l a c t i v e  with the D i v i s i o n  ' f i l e was p u l l e d  active  58 a n d 59  cases  T.B.  new  cases  a l l known Cases  Each  were  patients'  t o see i f t h e address a t time of d i a g n o s i s  the study a r e a . In t o t a l ,  234 c a s e s were f o u n d f o r t h e  s t u d y . The sample was d i s t r i b u t e d a s shown i n T a b l e X. Of patient  the  drug  participate moved  234 e l i g i b l e therapy, as  cases, 16%  out-patients  7 8 % (182) p a r t i c i p a t e d  ( 3 8 ) ) d i e d and because  they  6% ( 1 3 )  either  away o r were t r e a t e d a s i n - p a t i e n t s a t WCC.  54  in  out-  d i d not  disappeared,  TABLE X: T r e a t m e n t S t a t u s o f T.B. Year. REATMENT STATUS Outpat.  a t WCC  Outpat.  a t DCHC  Inpatient  1 977  1978 31  20.  only  DIED  7  6  DISAPPEARED  2  1  LEFT STUDY AREA TOTAL  The and  Vancouver  24  These  1 982  1 983  12  7  12  16  29  31  2  1  1  7  10  3  33  1  42  41  Canada c e n s u s  of Strathcona,  5  49  tracts  tracts  57, 58  encompass  t h e Downtown c o r e  boundaries  of t h e North H e a l t h U n i t of  boundaries  were  patient target area.  Western  Vancouver's  A)  choosen because  they  encompass  The DCHC was e s t a b l i s h e d  t h e downtown d i s t r i c t s  the  a n d *the  and a l s o correspond t o the Northern,  H e a l t h D e p a r t m e n t . ( S e e map i n A p p e n d i x  DCHC's  2  o f t h e s t u d y were c e n s u s  Statistics  districts  Southern  These  by  Boundaries.  Downtown-Eastside and  1981  Area  1  38  formal boundaries  59.  YEAR 1 979  2 31  2. Sample  Cases i n t h e Study  serve  residents  of  boundaries  were c h o o s e n b e c a u s e S t r a t h c o n a , t h e Downtown c o r e a n d  Downtown-Eastside city the  i n Vancouver.  to  the  have t h e h i g h e s t r a t e s o f t u b e r c u l o s i s  a n d t h e b e c a u s e n e a r l y a l l t h e TB d e a t h s past  Also, the  d e c a d e have o c c u r r e d i n t h e s e t h r e e  55  i n the  i n Vancouver districts.  over  7.3  VARIABLES: The  dependent  intervening WCC);  variable  variable  and  study  i s the out-patient  and the independent  demographic  in this  variables  medical  i s  compliance;  treatment  consist  of  characteristics  system  (DCHC  measureable  of  the  the or  socio-  tubercular  population.  (details  1.Independent V a r i a b l e s . A)  on c a t e g o r i e s  follow)  Socio-demographic.  a) Sex b) B i r t h p l a c e c ) Age d) R a c e . e) M a r i t a l  Status.  f) O c c u p a t i o n . g) L o c a t i o n . B)  Medical  Variables.  a) D i a g n o s i s . b) W h e t h e r  hospitalized  prior  to out-patient  c) If  hospitalized-  f o r how l o n g .  d) I f  hospitalized-  length  drug  pick-up  e) L e n g t h  of  a s an  of  interval  treatment.  between  discharge  and  f i r s t  out-patient.  out-patient  treatment.  f) A l c o h o l i s m . Information are  recorded  on seven  of  the eight  on a s t a n d a r d i z e d  each  out-patient  DCHC  are  v i s i t  referred  TB 40 form  t o t h e WCC.  from  socio-demographic  t h e WCC,  56  which  Because they  variables  i s f i l l e d  a l l patients  t o o have  a  TB  out at 40  at the form  containing Control.  this  information  on f i l e  less regular  of a p r o b l e m discussed One the  T.B.  TB  socio-demographic  variable  t h a n t h e o t h e r v a r i a b l e s . However, t h i s was l e s s  f o r h o s p i t a l i z e d p a t i e n t s as a l c o h o l i s m  i s regularly  i n t h e h o s p i t a l d i s c h a r g e summary.  of the medical v a r i a b l e s , 40  transcribed  form.  However,  the other  medical  variables  the sample,  were  i s type of o u t - p a t i e n t treatment.  patients either died,  left  the area a f t e r  a l l t r e a t m e n t a s an i n - p a t i e n t o r a t t e n d e d  treatment  on  Variables.  intervening variable  obtained  diagnosis i s also recorded  f r o m t h e p a t i e n t s h o s p i t a l d i s c h a r g e summary.  2.Intervening  The  of  A l c o h o l i s m o r drug a d d i c t i o n a r e not a s t a n d a r d p a r t of  t h e T.B. 40 f o r m so r e c o r d i n g o f t h i s was  at the D i v i s i o n  at  t h e WCC o r  DCHC.  Thus,  diagnosis, out-patient  out-patients  (with  e x c e p t i o n , a man u n d e r g o i n g c a n c e r c h e m o t h e r a p y who a l s o out-patient  tuberculosis  therapy  from h i s  In  private  one  received  physician)  a t t e n d e d t h e WCC o r DCHC. 3.Dependent  Variables.  Attendance  compliance  to  dependent v a r i a b l e . Compliance at drug p i c k - u p In  terms  calculated appointment percentage patient first  out-patient  treatment  is  the  i s measured i n terms o f a t t e n d a n c e  appointments.  of by  attendance dividing  attendances compliance  treatment  was  to actual  and  figure  appointments, attendances  multiplying  by  f o r each patinB>i.  compliance by 100  was  expected to  Length  m e a s u r e d i n weeks from t h e d a t e  give of  a  out-  of the  t o the l a s t drug p i c k - u p .  I t must be p o i n t e d o u t t h a t t h e number o f e x p e c t e d 57  attendances  at  both  c l i n i c s d i f f e r e d enormously.  appointments over  a  were m o n t h l y ,  three.  varied  At  the  appointments  from  DCHC,  t r e a t m e n t regime  over  nine  However,  a maximum o f n i n e  the  number  months  was  attend  thirty  of  a  a p p r o x i m a t e l y one treatment  s i x appointments  of  minimum  of  drug  pick-up  recommended.  hundred  regime  over  Thus  a  For a  attendances and  eighty.  would  be  expected  nine  month  span.  a t t e n d a n c e e x p e c t a t i o n s were q u i t e d i f f e r e n t a t t h e two  Attendance maximum  compliance  out-patient  the  modalities.  was m e a s u r e d a t b o t h  treatment  clinics  over  a  l e n g t h o f 12 months b e c a u s e  this  minimum l e n g t h o f o u t - p a t i e n t t r e a t m e n t p r e s c r i b e d  for  f o r the period  person  more  to  expected  c l i n i c s and w i t h i n t h e DCHC a c r o s s t r e a t m e n t  t h e WCC  pick-up  number  t h e number o f e x p e c t e d c l i n i c  someone on a w e e k l y  Clearly,  a  drug  e v e r y two months o r q u a r t e r l y .  d e p e n d e d on t h e t r e a t m e n t r e g i m e  daily  was  WCC  t r e a t m e n t c o u r s e o f n i n e months t h e e x p e c t e d  appointments  to  At the  1977--79. T h u s , a p p o i n t m e n t s  occuring after  h a d been i n o u t - p a t i e n t t h e r a p y a t e i t h e r  than  clinic  12 months were n o t i n c l u d e d i n t h e c o m p l i a n c e  for  scores.  CODING  7.4  D a t a were  transferred  designed  data  transfer  was p e r f o r m e d  collection  U n i v e r s i t y o f B.C. author.  f r o m t h e T.B. form.  Ninety  records to  a  percent  of  In  the  by a r e s e a r c h a s s i s t a n t e m p l o y e d  (U.B.C) The r e m a i n i n g  10% was p e r f o r m e d  data  by  coded order  carry  o u t t h e a n a l y s i s some o f  58  by  Once a l l t h e d a t a  a f r e q u e n c y d i s t r i b u t i o n was r u n f o r a l l to  the  by t h e  A l l t h e d a t a c o d i n g and c o m p u t e r e n t r y were p e r f o r m e d  t h e a u t h o r a c c o r d i n g t o SPSS:X s p e c i f i c a t i o n s . were  specially  the  variables. d a t a were  recoded. Recoded independent Location:  The  variables  approximately  were:  100 s t r e e t names  numbers were r e c o d e d  i n t o 4 a r e a s based  (see  B).  map i n A p p e n d i x  and  200  street  on p r o x i m i t y t o t h e DCHC  The r a t i o n a l e b e h i n d r e c o d i n g a r e a s was  that proximity t o the c l i n i c  may a f f e c t c l i n i c  attendance  because  t h e p o p u l a t i o n under s t u d y i s p o o r a n d may have r e s t i t c t e d to  access  transportation. Two  areas,  concentric  each  18  squares around  square  blocks  were  constructed  t h e DCHC. These a r e a s  core and o u t e r - c o r e areas c l o s e s t  1 and 2  t o the c l i n i c .  in  are the  A l s o , t h e s e two  a r e a s encompass t h e DCHC T.B. n u r s e s ' r e g u l a r s u r v i e l l a n c e r o u t e . The  T.B.  nurse  thus p a t r o l s about  a c t i v e s u r v e i l l a n c e may be a f a c t o r  half  t h e Study  influencing  Area.  This  the compliance of  pat i e n t s . A  t h i r d a r e a - a r e a 3- e n c o m p a s s e s t h e e a s t e r n a n d w e s t e r n  of  the boundaries.  south-west  of  discharge categories.  4 i sfarthest  from t h e c l i n i c  variables  c o n s i s t i n g of i n t e r v a l data l i k e  hospitalization,  and  first  These  and  interval  d r u g p i c k - u p were r e c o d e d  between into  age,  hospital 5  ordinal  c a t e g o r i e s were c o n s t r u c t e d s o a s t o c o n t a i n  e q u a l f r e q u e n c i e s by u s i n g t h e c u m u l a t i v e p e r c e n t a g e twenty  i n the  corner of the study area.  Independent length  Area  edges  percent.  These w o r k e d o u t a s f o l l o w s : Age: 1) 1 t h r o u g h 41 2) 42 t h r o u g h 50 59  i n t e r v a l s of  3) 51 t h r o u g h  59  4) 60 t h r o u g h  67  5) g r e a t e r  t h a n 68.  Length of H o s p i t a l i z a t i o n :  ( i n weeks)  1) 1 t h r o u g h 6 2) 7 t h r o u g h  13  3) 14 t h r o u g h  17  4) 18 t h r o u g h  24  5) g r e a t e r  t h a n 25 weeks.  I n t e r v a l between D i s c h a r g e and D r u g P i c k - U p :  ( i n weeks)  1) 1 2) 2 t h r o u g h 5 3) 6 t h r o u g h 9 4) 10 t h r o u g h  13  5) g r e a t e r t h a n  14 weeks.  L e n g t h o f o u t - p a t i e n t t r e a t m e n t : ( i n weeks) 1) 1 t h r o u g h  27  2) 28 t h r o u g h  38  3) 39 t h r o u g h  50  4) 51 t h r o u g h  60  5) g r e a t e r  t h a n 61 weeks.  Independent  variables  c o n s i s t i n g of  recoded as f o l l o w s : Occupation: 1) u n e m p l o y e d 2) r e t i r e d 3) e m p l o y e d .  60  categorical  data  were  Marital  status:  1) S i n g l e 2) M a r r i e d 3) Widowed a n d d i v o r c e d . Diagnosis: 1) F a r a d v a n c e d  active  2) M o d e r a t e l y a d v a n c e d 3) M i n i m a l l y a d v a n c e d 4) 0 t h e r .  active active  (eg.) e x t r a - p u l m o n a r y  T.B.  Dependent V a r i a b l e : Percent  compliance:  1) 1 t h r o u g h 24 2) 25 t h r o u g h 50 3) 51 t h r o u g h 73 4) 74 t h r o u g h 99 5) 100 % c o m p l i a n c e . 7.5 DESIGN BIAS A potential carried  o u t by two p e o p l e .  the d a t a . cases,  However, (less  collection ten  s o u r c e s o f b i a s a r i s e s b e c a u s e d a t a c o l l e c t i o n was  than  A U.B.C.  t h e a u t h o r g a t h e r e d d a t a f o r 25 1 0 % ) . To  test  between t h e two p e o p l e ,  c a s e s p r o c e s s e d by t h e U.B.C.  from  the  records to the data  between  the  Square  test  e m p l o y e e e g a t h e r e d most o f  the  reliability  t h e author randomly  No  of  collection  sheet.  significant  data  selected  employee and t r a n s f e r r e d  data  Discrepancies  two s e t s o f 10 d a t a s h e e t s were r e c o r d e d performed.  outstanding  and C h i -  discrepancies  were  o b s e r v a b l e between t h e two p e o p l e . Another  source  of b i a s a r i s e s because of d i f f e r e n c e s i n the 61  volume and d e t a i l o f T.B.  records.  In p a r t i c u l a r ,  p a t i e n t s who  h a v e been h o s p i t a l i z e d have a h o s p i t a l d i s c h a r g e summary a s of  their  T.B.  record.  Many h o s p i t a l i z e d p a t i e n t s  a l s o have  social  w o r k e r ' s a s s e s s m e n t on f i l e .  provide  a more d e t a i l e d s o c i o - d e m o g r a p h i c a n d m e d i c a l p r o f i l e  is available for non-hospitalized  These  part  expanded  a  T.B. f i l e s than  patients.  7.6STUDY DESIGN 1 . Q u e s t i o n 1. A  retrospective  effectiveness A)Population  selection means  largely  that  Clearly,  selection  of  c o m p l i a b i l i t y has r e s u l t e d sub-groups  of  To  the basis and  t h e DCHC  perceived treat  very  patients  on t h e b a s i s  of  perceived  i n two s o c i o - d e m o g r a p h i c a l l y  distinct  groups  at  attending  t h e two  each  clinic.  clinics  are  so  t h e s e two g r o u p s c a n n o t be u s e d t o measure t h e e f f e c t  t y p e on c o m p l i a n c e .  meaningfully  compliance attending  i t was t h e DCHC  compare  the effect  necessary with  to  of  cases  at  WCC c a s e s i n t e r m s  t h e WCC i n t h e  both  retrospectively  d e m o g r a p h i c r;;,d m e d i c a l v a r i a b l e s . C o n t r o l s 75  of  Table IX)  tuberculosis out-patients  the treatment  dissimilar,  on  t h e WCC  groups of p a t i e n t s . ( S e e  of c l i n i c  the  and S e t t i n g .  compliability  Because  evaluate  o f t h e DCHC i n t e r m s o f c o m p l i a n c e .  Physician  different  matched-case c o n t r o l study t o  1977-79  of  clinics match major  were s o u g h t among t h e  period.  Once  matched,  i n c o m p l i a n c e between t h e two g r o u p s a r e much  likely  to the intervening  variable, out-patient  62  cases socio-  differences due  on  more  treatment  type, than  t o s o c i a l background.  The c o n t r o l g r o u p was  c a s e s a t t h e WCC i n t h e 1 9 7 7 - 7 9 p e r i o d  t h e 75  and t h e e x p e r i m e n t a l  was t h e 76 c a s e s a t t h e DCHC i n t h e p e r i o d  group  1981-83.  B)Matching. 76 DCHC p a t i e n t s  The  were d i v i d e d  i n t o g r o u p s on t h e b a s i s o f  r a c e a n d b i r t h p l a c e . The same p r o c e d u r e was done f o r t h e 75  sex,  patients  who a t t e n d e d t h e WCC f r o m  matched.  Within  birthplace  these  exact  c a s e s were m a t c h e d  to the f o l l o w i n g  matchings (pair-wise)  These  groups  f o r sex,  were  race  and  i n o r d e r and a c c o r d i n g  process:  1. Age - was m a t c h e d w i t h i n  5 y e a r s o f t h e DCHC p a t i e n t .  2. A r e a - was matched t o w i t h i n 3. A l c o h o l i s m -  1977-79.  alcoholics  1 district.  were  a l c o h o l i c s were m a t c h e d w i t h  matched w i t h  non-alcoholics  a l c o h o l i c s and n o n o r unknowns.  4. D i a g n o s i s - was m a t c h e d a s c l o s e l y a s p o s s i b l e . 5. Whether t h e p a t i e n t 6. M a r i t a l s t a t u s far  was h o s p i t a l i z e d - was m a t c h e d i f p o s s i b l e .  and o c c u p a t i o n a l  status  were a l s o matched up  as  as p o s s i b l e . t h i s p r o c e d u r e 55 o u t o f t h e 76 DCHC c a s e s were m a t c h e d  Using exactly  f o r sex,  race and b i r t h p l a c e w i t h  treated  a t t h e WCC.  When C h i S q u a r e t e s t s were p e r f o r m e d on t h e  110 c a s e s , no s i g n i f i c a n t d i f f e r e n c e s groups  i n terms of age, a r e a ,  marital  status,  diagnoses  55 o u t o f t h e 75 c a s e s  alcoholic  whether t h e p a t i e n t  of p a t i e n t s .  were o b s e r v a b l e between t h e ,  occupational  and  was h o s p i t a l i z e d o r n o t a n d  This procedure r e s u l t e d  i n matching  of  73% o f t h e DCHC c a s e s . This normal  stratified  matching process r e s u l t e d  d i s t r i b u t i o n s so t h a t  a non-parametric 63  i n a s e r i e s of nonstatistical  test  was to  most a p p r o p r i a t e . test A  A W i l c o x o n S i g n e d Rank T e s t was  for a difference pair-wise  i n c o m p l i a n c e between t h e matched  match  with  the  criteria  a c h i e v a b l e f o r 21 c a s e s a t t h e DCHC. left  performed 25  o u t of t h e t e s t i n g p r o c e s s .  outlined  was  These c a s e s were  However,  pairs. not  therefore  t h e y were a n a l y z e d t o  d e t e r m i n e t h e e f f e c t of t h e m i s s i n g c a s e s on t h e e v a l u a t i v e outcome. (See C h a p t e r 8 S e c t i o n  test  8.1)  2. Q u e s t i o n 2. What  c h a r a c t e r i s t i c s o r c o m b i n a t i o n s of c h a r a c t e r i s t i c s  predict model  compliance  t o d r u g t h e r a p y a t t h e DCHC?  t o h a n d l e t h i s p r o b l e m was  difficult  A  to f i n d  statistical because  independent v a r i a b l e s a r e m a i n l y i n nominal form w h i l e is  in ordinal  scale,  By c o n s i d e r i n g t h e o r d i n a l s c a l e an 1 t e c h n i q u e s c a n be u s e d . In p a r t i c u l a r , 35  Classification statistic  Analysis  it  (MCA)  produces  was  which  choosen  because  approximate  to  of a  the  compliance  form.  ANOVA  best  interval Multiple the  beta  regression  coef f i c i e n t . B e s i d e s p r o d u c i n g a measure o f s t r e n g t h o f a s s o c i a t i o n i n d e p e n d e n t and d e p e n d e n t in  variables,  t e r m s o f t h e amount o f v a r i a t i o n  a l l o w s f o r a more d e t a i l e d a n a l y s i s o f t h e d a t a t h a n  MCA  predictability  can  each  independent  variable  This  Also,  category i n  from t h e d e p e n d e n t  results  caused  accomplished  each  also presents  mean  be  by  MCA  between  variable. would  u s i n g ANOVA a l o n e . tell  how  of the f i r s t  model as a whole can be  much a s e c o n d v a r i a b l e a d d s variable. Finally,  ascertained.  64  to  the  t h e e f f e c t s of t h e  3. Q u e s t i o n Who  3.  benefits  a n d who d o e s n ' t  benefit  from t r e a t m e n t  at the  DCHC? This  question  scores  was b e s t a n s w e r e d by d i v i d i n g  o f a l l 76 c a s e s a t t h e DCHC i n t o q u a r t i l e s .  c a s e s were b r o k e n down i n t o q u a r t i l e s , through  64%  quartile,  represented the f i r s t  socio-demographic high  f o r compliance.  When t h e 76 s c o r e s from  65-92% t h e  independent  4.  4.  Characterization  i s paid  a  and  who  identified  as  predictive  of  section.  o f ' d r o p - o u t s ' a t t h e DCHC.  this thesis  attendance t o appointments While  this  i sa  h a s been t h e  variable.  variable,  when a n a l y s e d i n i s o l a t i o n g i v e s us l i t t l e or success of treatment as  example,  relation  t o t h e r o l e of  dependent  For  in  t o i d e n t i f y who b e n e f i t s  variables  i n the previous  failure  quartile.  From t h e s e c r o s s t a b u l a t i o n s  particular attention  compliance  on  second  f r o m t h e DCHC p r o g r a m .  In t h i s a n a l y s i s ,  Section  variables  0  a n d t r e a t m e n t p r o f i l e was b u i l t up f o r t h e l o w  compliance q u a r t i l e s  does n o t b e n e f i t  In  quartile,  were r u n f o r i n d e p e n d e n t  to these q u a r t i l e s  those  compliance  compliance  93-99% t h e t h i r d q u a r t i l e a n d 100% t h e f o u r t h  Crosstabulations  to  the  a  patient  opposed  who a c h i e v e d  dropped  out of the c l i n i c  success  t h a n a p e r s o n who a t t e n d e d  o v e r a 45 week p e r i o d .  fairly  easily  to  Or,  65%  measured  information attendance.  100% c o m p l i a n c e  a f t e r 8 weeks may have l e s s of his/her  major  but  treatment appointments  a p e r s o n c o u l d be 100% c o m p l i a n t b u t  d r o p o u t o f t h e p r o g r a m a f t e r 6 weeks. A l t h o u g h s u c h a c a s e  65  would  be  registered  as  100% c o m p l i a n t he/she  may  be  a  treatment  failure. Measuring  attendance compliance  o n l y does n o t t e l l  us how many  d r o p - o u t s o c c u r i n t h e p r o g r a m o r who t h e d r o p - o u t s a r e . To r o u n d out  t h e e v a l u a t i o n o f t h e DCHC,  rate  i s needed.  To  i d e n t i f y drop-outs,  some a s s e s s m e n t  of the drop-out  t h o s e p a t i e n t s who a t t e n d e d t h e  DCHC  f o r 6 months o r l e s s were i d e n t i f i e d . B e c a u s e many member o f t h i s g r o u p h a d been h o s p i t a l i z e d treatment,  they  were  f o r some l e n g t h p r i o r t o o u t - p a t i e n t  e x p e c t e d t o a t t e n d t h e DCHC  for varying  p e r i o d s l e s s t h a n 6 months. When t h i s g r o u p was s e p a r t e d o u t from t h e r e s t , t h e r e a l d r o p - o u t s were i s o l a t e d a n d d e s c r i b e d .  66  CHAPTER 8. THE EFFECT OF TWO TYPES OF C L I N I C SYSTEMS ON COMPLIANCE TO TUBERCULOSIS CHEMOTHERAPY. RESULTS AND DISCUSSION The  reader i s reminded  Which  clinic  predict  8.1  best promotes c o m p l i a n c e ? ;  compliance  doesn't  benefit  a t t h e DCHC?;  2) What  factors  and 3) Who b e n e f i t s  best  and  who  from t r e a t m e n t a t t h e DCHC?  QUESTION 1: The  t h a t t h e t h r e e t h e s i s q u e s t i o n s a r e : 1)  which c l i n i c  results  best promotes  compliance?  of the Wilcoxon Matched-Pairs Signed-Ranks  using compliance with appointments  as dependent v a r i a b l e  Test  i n Table  XI . TABLE X I : W i l c o x o n M a t c h e d - P a i r s S i g n e d - R a n k s Mean Rank  Cases  12.00  3  28.41  51  -Ranks (DCHC l e s s t h a n  Ties  55  compliance that  TOTAL 2-TAILED P= Test  between  tests  .0000  for significant  differences  each p a i r of matched c a s e s .  The t e s t  we must r e j e c t t h e n u l l h y p o t h e s i s t h a t c o m p l i a n c e  two c l i n i c s The  i s e q u a l a t p=0.000  mean  compliance  compared  to  indicate  that  It  WCC)  (DCHC e q u a l t o WCC)  Z = - 6 .0831 Wilcoxon  WCC)  +Ranks (DCHC g r e a t e r t h a n  1  The  Test.  must  be  shows i n the  level.  f o r t h e 55 c a s e s a t  83% f o r matched c a s e s a t t h e compliance  in  i s significantly  remebered t h a t t h i s r e s u l t  67  the  DCHC.  WCC  was  These  better at i s valid  the  37%  results DCHC.  f o r the  55  matched were  cases.  not  What a b o u t  matcheable  t h e 21 unmatched c a s e s ?  because  o f t h e age  These  disparity  cases  between  the  e x p e r i m e n t a l and c o n t r o l t i m e p e r i o d s . ( T a b l e X I I ) TABLE X I I : Mean Ages I n C o n t r o l a n d E x p e r i m e n t a l G r o u p s By R a c e : Race  1977-79  White Nat i v e Chinese  1981-83  59.0 49.3 63.8  The  mean  registered  ages in  The  explainable recent  and  decrease because  Native  patients  in were  by a p p r o x i m a t e l y  of the i n f l u x  the area. treated  curious  of Vietnamese  Because  shift cohort  may  refugees.  most o f t h e s e y o u n g e r  a t t h e WCC d u r i n g  the  7 be  These  Chinese  T.B.  Chinese  1981-83  period,  group.  treated  d u r i n g 1977-79.  This  i n t h e WCC  relatively  a g e - s h i f t w i t h i n the Study Area over a 6 year and  years  f o r 10 N a t i v e and 11 W h i t e c a s e s t r e a t e d a t t h e DCHC  group  downward  5  i n t h e mean age f o r C h i n e s e c a s e s  between 1981-83, age m a t c h e s were s i m p l y n o t a v a i l a b l e Control  patients  F o r C h i n e s e t h e d e c r e a s e was about  m a t c h i n g was n o t an i s s u e f o r t h i s However,  1981-83  tubercular  a r r i v a l s added a y o u t h f u l component t o t h e  population  Unmatched  49.2 44.8  t h e Study Area dropped  o v e r t h e two t i m e p e r i o d s . years.  unmatched  55.7 44.7 56.0 f o r White  and  may be c a u s e  f o r c o n c e r n and f u r t h e r  i s p a r t i c u l a r l y c u r i o u s f o r the white group  large  span  study.  (This  because  e f f e c t p r e d i c t s h i g h e r r a t e s f o r o l d e r segments  is  the  of  this  group). How effect  does  t h e e x c l u s i o n o f t h e s e 21 y o u n g e r  the comparison  i s shown i n  Section  unmatched  cases  o f c o m p l i a n c e between t h e two c l i n i c s ? 8.2,  younger 68  patients  tend  to  be  As less  compliant  a t t h e DCHC.  cases  which a r e l i k e l y  result  showing  be  Thus,  the matching  p r o c e s s has e x c l u d e d  among t h e most n o n - c o m p l i a n t  Our  b e t t e r c o m p l i a n c e a t t h e DCHC v e r s u s t h e WCC  qualified  by s t a t i n g t h a t c o m p l i a n c e a t t h e DCHC was  t h a n a t t h e WCC f o r 7 3 % o f DCHC c a s e s .  must better  F o r t h e 2 7 % o f DCHC c a s e s  w h i c h were g e n e r a l l y y o u n g e r p a t i e n t s , no c o n c l u s i o n s clinic  group.  on r e l a t i v e  e f f i c a c y i n t e r m s o f c o m p l i a n c e c a n be d r a w n .  Other  medical  variables  f o r t h e s e matched  examined t o a s s e s s t h e o v e r a l l impact  groups  c a n be  o f t h e DCHC on t u b e r c u l o s i s  t r e a t m e n t o f t h e matched group.  T a b l e X I I I compares t h e e f f e c t o f  clinic  treatment  type  hospitalized were  on  length  of  prior to out-patient  for  those  patients  treatment.(Thirty-five  h o s p i t a l i z e d i n each group p r i o r t o o u t - p a t i e n t  TABLE X I I I : T o t a l L e n g t h o f T.B. L e n . o f Hosp. (weeks)  CLINIC  Treatment  I n t e r v a l between d i s c h . a n d o.p.  cases  treatment)  f o r H o s p i t a l i z e d Cases  L e n . o f o.p. T o t a l L e n treatment. of t r e a t .  WCC  11.3  3.1  43. 1  57.4  DCHC  4.7  1. 1  37.2  43.0  the  two  clinics  hospitalized than  DCHC  difference patients.  treatment  lengths  was  patient  different.  p a t i e n t s t r e a t e d a t t h e WCC s p e n t patients  i n treatment.  i s accounted  Matched  14.4 weeks  Approximately  f o r by t h e l o n g e r  more  half  h o s p i t a l stays  this of  ( I t i s e s s e n t i a l t o remember t h a t t h e e x p e c t e d  of t r e a t m e n t a t t h e WCC o u t - p a t i e n t 79  were  clinic  12-24 months s o t h a t we w o u l d  p r o g r a m between  expect the length of  t r e a t m e n t a t t h e WCC t o be s i g n i f i c a n t l y g r e a t e r 69  WCC  length 1977out-  than f o r  t h e DCHC.) It  i s a l s o u s e f u l t o compare t h e e x p e r i e n c e o f h o s p i t a l i z e d  v e r s u s n o n - h o s p i t a l i z e d p a t i e n t s a t t h e two c l i n i c s  (Table XIV).  TABLE X I V : C o m p a r i s o n  of H o s p i t a l i z e d and N o n - h o s p i t a l i z e d  Variable  WCC  DCHC  H o s p i t a l i z e d Not Length of out-pat. treatment (weeks) Complian. (percent)  H o s p i t a l i z e d Not  hosp.  58.8  37.2  40.6  29.2  51 .8  82.8  88.3  hospitalized of  hosp.  43. 1  Table XIV  terms  Cases.  shows t h a t t h e e x p e r i e n c e o f h o s p i t a l . i z e d a n d non p a t i e n t s w i t h i n both c l i n i c s  length  of  out-patient  i s quite different i n  treatment  and  attendance  c o m p l i a n c e . That  i s , h o s p i t a l i z e d p a t i e n t s a t both c l i n i c s  on  treatment  out-patient  treatment  than  explainable patients population  non-hospitalized  because  non-hospitalized I n summary,  and  patients.  as  non-complianct  those p a t i e n t s perceived  for  o u r matched groups.  The DCHC shows an  reflected While  t h a n t h e WCC.  hospitalize  of  A.ls.*«,  patients  i n the compliance length  to  likely  slotting  those  the h o s p i t a l i z e d into the  i s clearly a significant difference of compliance  to  is  as compliant  WCC a n d DCHC i n t e r m s  tend  less  population.  there  record  This  into  the  compliance  comply  of t h e s e l e c t i o n procedure  perceived and  f o r l e s s time  remain  to out-patient  out-patient  70  as  treatment  50%  the fact that,  perceived  statistics  almost  better  clinicians  non-compliant  computed a t b o t h  treatment  between  is  not  is  clinics. strictly  comparable length  length less  years  than the t o t a l  of  treatment  Given t h i s  treatment  i t i s clear  l e n g t h at the  that  a p r o g r e s s i v e one  WCC  factor alone, i t i s l i k e l y  t h e DCHC ( f o r d i f f i c u l t - t o - t r e a t  for that  the was the the  patients) i s  i n t e r m s o f e f f i c a c y o f t r e a t m e n t but  also progressive in f i s c a l 8.2  e x p e c t a t i o n s of  o f t r e a t m e n t a t t h e DCHC f o r t h e y e a r s 1981-83  1977-79.  evolution only  (because  were d i f f e r e n t a t t h e two c l i n i c s )  total much  a t t h e two c l i n i c s  not is  terms.  Q u e s t i o n 2: What f a c t o r s b e s t p r e d i c t c o m p l i a n c e a t t h e DCHC? According  factors  to  likely  inconclusive  Chapter  socio-demographic  a f f e c t compliance.  The  and  literature  treatment  is  somewhat  as t o t h e n a t u r e o r t h e s t r e n g t h o f t h e e f f e c t s  socio-demographic particularly  6,  as  or  treatment  variables  on  of  compliance,  t h e l i t e r a t u r e on c o m p l i a n c e among a  generally  alcoholic alienated population i s negligable. To  determine  Analysis treatment performed 81-83  who  of  w h i c h v a r i a b l e s may  V a r i a n c e was  a  p  occupation  each  These  were period  t h e DCHC. variables significantly affecting  l e v e l of l e s s t h a n and  and  analyses  on t h e 76 c a s e s w i t h i n t h e s t u d y a r e a d u r i n g t h e attended  One-Way  socio-demographic  v a r i a b l e measured i n the s t u d y .  Socio-demographic at  done f o r  a f f e c t compliance a  race,  .05  i n that  were order.  age, The  area,  compliance alcoholism,  medical  variables,  d i a g n o s i s and w h e t h e r h o s p i t a l i z e d , had an e f f e c t a t p v a l u e s  less  than  not  0.1.  reliably  The  effect  of  sex on c o m p l i a n c e  m e a s u r e d b e c a u s e t h e number of f e m a l e s  a b o u t 12% o f o u r  sample.  71  is  probably  i s ten which  is  TABLE XV: Oneway Analysis of V a r i a n c e for 12 I n d e p e n d e n t V a r i a b l e s i n R e l a t i o n t o t h e Dependent V a r i a b l e - C o m p l i a n c e . Independent  Variable  F  Socio-demographic: AGE  Value  F-Ratio  Prob.  5.6  0.0005  AREA  4. 1  0.0094  ALCOHOLISM  4.8  0.0303  OCCUPATION  3.4  0.0358  RACE  3.1  0.0491  BIRTHPLACE  2.0  0.1098  MARITAL  1 .8  0.1684  0. 1  0.6985  3.5  0.0634  DIAGNOSIS  2. 1  0.0961  TYPE OF O.P. TREAT  0.6  0.6368,  LENGTH OF HOSP.  0.5  0.6395  0.3  0.8265  STATUS  SEX Medical: HOSPITALIZED?  -LENGTH OF O.P. Based  TREAT  on r e s u l t s i n s e c t i o n 8.1 and t h e s e l e c t i o n b i a s  h o s p i t a l i z a t i o n with perceived  non-compliance  the v a r i a b l e h o s p i t a l i z a t i o n w i l l To  i t i s expected  more c l o s e l y a n a l y z e t h e e f f e c t o f t h e s e v a r i a b l e s on  the  seven  variables  c o m p l i a n c e . The...results  found  are presented  72  that  have an i m p a c t on c o m p l i a n c e .  d e p e n d e n t v a r i a b l e M u l t i p l e C l a s s i f i c a t i o n A n a l y s i s was with  linking  significantly in  Table XVI.  the  performed affecting  TABLE XVI:MCA o f 7 v a r i a b l e s i n r e l a t i o n Unadjusted Eta  Variable  t o Compliance.  Adjusted f o r Independents Beta  Area  .39  .38  Age  .39  .29  Diagnosis  .21  .26  Race  .28  .20  Hospitalize  .19  .15  Alcoholism  .10  .13  Occupation  .20  .09  The  beta s t a t i s t i c  i s a standardized regression c o e f f i c i e n t i n  the  s e n s e used' i n m u l t i p l e r e g r e s s i o n .  the  adjusted  statistic  category  effects  i s a correlation  c a t e g o r y e f f e c t s f o r each  area  occupation adjusted  and  and  f o r each  The e t a  r a t i o associated with the  unadjusted  variable.  compliance  f o r each v a r i a b l e t h e c o r r e l a t i o n is  strongest  compliance weakest.  f o r the  with  variable.  By v i e w i n g t h e e t a s t a t i s t i c between  Beta i s a s s o c i a t e d  effects  of  with  When t h e e t a  the  between  statistic  is  nominal  variables,  a l c o h o l i s m , d i a g n o s i s , h o s p i t a l i z a t i o n and a r e a r e m a i n  relatively  u n a f f e c t e d by t h e o t h e r v a r i a b l e s . and  age on t h e d e p e n d e n t v a r i a b l e  However,  the e f f e c t s of race  i s r e d u c e d by a b o u t  one  third  What do t h e s e r e s u l t s mean? T a k i n g t h e model a s a w h o l e ,  area,  and t h e e f f e c t o f o c c u p a t i o n by a b o u t  age,  diagnosis  predictive  of  prediction  a half.  and r a c e ( i n t h a t o r d e r ) a p p e a r compliance.  While  v a r i a b l e s may be t h e most p r e d i c t i v e of  other  that  i s not  shown.  T a b l e XVI  shows  f o r compliance  This i s 73  t o be  shown  in  the these  most four  the d i r e c t i o n Table  XVII.  TABLE X V I I : MCA T a b l e Showing D e v i a t i o n s from t h e G r a n d Variable AREA Area Area Area Area AGE  1 2 3 4  +Category  9.2 2.36 -11.7 -19.9  8.5 3.1 -12.2 -19.7  1-41 42-50 51-59 60-67 68-98  17 8 16 12 9  -14.0 -4.2 2.8 12.3 8.8  -6.5 -5.8 -2. 1 13.5 3.3  F a r Adv. Mod. Adv. Minimal Other  23 22 12 5  3.1 -1.2 3.2 -17.0  5.4 0.2 -2.5 -19.7  21 37 4  -8.2 2.5 19.8  -3.7 0.1 18.6  47 15  -2.8 8.8  -2. 1 6.7  49 13  -1 .3 4.8  1 .8 -6.6  12 44 6  10.1 -2.8 0.3  -3.3 0.2 5.2  Nat i v e White Chinese HOSPITALIZED? Yes No ALCOHOLISM Yes No OCCUPATION Employed Unemployed Retired Table this  X V I I shows t h a t  analysis,  unadjusted mean  Adj.for I n d . Dev.  22 (Core) ( O u t e r C o r e ) 23 (Wings) 10 7 (Farthest)  DIAGNOSIS  RACE  U n a d j . Dev.  N  produced  f o r t h e 76 c a s e s a t t h e DCHC,  t h e c o m p l i a n c e mean ( g r a n d mean)  deviation  Mean=79  c o l u m n shows t h e d e v i a t i o n  by e a c h f a c t o r w i t h i n  d e v i a t i o n shows t h e e f f e c t o f e a c h  categories.  was  used  in  79%.  The  from t h e The  grand  adjusted  factor a f t e r a l l other  factors  are c o n t r o l l e d f o r . Table XVII terms impact  of  appears t o c o n f i r m the r e s u l t s of  hospitalization.  S e c t i o n 8.1 i n  I t i s somewhat s u r p r i s i n g  of the v a r i a b l e h o s p i t a l i z a t i o n appears  74  that  the  small r e l a t i v e to  the  other  for  v a r i a b l e s as h o s p i t a l i z a t i o n  perceived In  disease  selection  variable  compliance.  terms  relationship  isa  of  diagnosis,  between  severity  there  s e v e r i t y of  is a  disease  fairly and  consistent  compliance.  i n c r e a s e s so does t h e p o s i t i v e d e v i a t i o n  As from  t h e c o m p l i a n c e mean. Area  also  Positive  shows a c o n s i s t e n t r e l a t i o n s h i p  deviations  from  the  compliance  increasing proximity to the c l i n i c . with  Natives having  being  a negative  with  mean  compliance.  increase  with  Race shows t h e same c o n s t a n c y  d e v i a t i o n from t h e  a t t h e mean and C h i n e s e h a v i n g  mean,  a large p o s i t i v e  Whites  deviation  f r o m t h e mean. Patient deviation from  categories  over  f r o m t h e mean.  t h e mean.  60  years  of  age  had  a  Those u n d e r 60 had n e g a t i v e  deviation  F o r t h e u n d e r 60 c a t e g o r i e s t h e r e was a  increasing negative  d e v i a t i o n f r o m t h e mean g o i n g  positive  regular  from o l d e s t t o  youngest.The  r e l a t i o n s h i p between age and c o m p l i a n c e i s shown i n  Table  XVI11. TABLE X V I I I : Mean C o m p l i a n c e f o r Recoded Age C a t e g o r i e s . AGE CATEGORY  MEAN COMPLIANCE  1 t o 41 42 t o 50 51 t o 59 60 t o 67 o v e r 68 The  (%)  63.3 72. 1 83.7 90.0 98.9 r e s u l t s f o r the v a r i a b l e alcoholism are  appears  that  alcoholism  Results  indicate  i s not  correlated  t h a t when a d j u s t e d  75  f o r other  interesting. with  It  compliance.  v a r i a b l e s i n the  model,  n o n - a l c o h o l i c s comply l e s s than a l c o h o l i c s .  has  direct  a  selection  b e a r i n g on t h e c l i n i c  criteria  b e c a u s e one  i n t o t h e DCHC i s a l c o h o l i s m .  most c l i n i c i a n s f e e l a l c o h o l i s m  of  a very minor f a c t o r  i s a major i n d i c a t o r  c o m p a r e d t o age,  result  the  In other  n o n - c o m p l i a n c e . The l i m i t e d r e s u l t s h e r e show t h a t be  This  Race,  a l c o h o l i s m may  area and r a c e .  o f c o m p l i a n c e f o l l o w e d by age a n d  hospitalization,  predictors  alcoholism  for compliance.  relationships  are presented  8.3 QUESTION 3: Who b e n e f i t s at  and  occupation  A more d e t a i l e d i n the next  words,  of p o t e n t i a l  In summary, a r e a o f r e s i d e n c e i n r e l a t i o n t o t h e c l i n i c strongest predictor  major  i s the  diagnosis. a r e weaker  exploration  of these  section.  a n d who d o e s n ' t b e n e f i t  from  treatment  t h e DCHC? In  this  section  quartiles  i n terms  crosstabulations  and  socio-demographic using  t h e 76 c a s e s a t t h e DCHC were  the 5  of  their  compliance  breakdowns  and  run t o develop  and t r e a t m e n t c h a r a c t e r i s t i c s  major  predictive  variables:  divided a a  into  series  of  profile  of  f o r a l l 4 groups  area,  age,  race,  d i a g n o s i s a n d h o s p i t a l i z a t i o n . When t h e 76 c a s e s were b r o k e n down into quartiles, the  first  quartile,  c o m p l i a n c e s c o r e s f r o m 0 t h o u g h 64%  represented  q u a r t i l e , 65-92% t h e s e c o n d q u a r t i l e , 93-99% t h e s e c o n d and  100% t h e f o u r t h  quartile.  76  1.Socio-demographic  Variables:  A)AGE. TABLE X I X : C r o s s t a b , o f Age C a t e g o r y by C o m p l i a n c e Q u a r t i l e . | ( F i g u r e i n b r a c k e t s i s % w i t h i n e a c h age c a t e g o r y ) Quart i l e  1 -41  1 low 2 3 4 high The For  9 (45) 8 (40) 2 (10) 1 (5)  the  the  4 1 4 3  4 3 6 7  (34) (8) (33) (25)  60-67  (20) (15) (30) (35)  mean age o f t h e h i g h c o m p l i a n c e low c o m p l i a n c e  difference of  A G E 51-59  42-50  1 6 3 3  (8) (46) (23) (23)  1 (10) 0 1 (10) 8 (80)  q u a r t i l e was 62.7 y e a r s .  q u a r t i l e t h e mean age was 42.3  years  a  o f a p p r o x i m a t e l y 20 y e a r s . I n t e r m s o f c o m p l i a n c e , 8 5 %  youngest  age g r o u p (1-41) a r e b e l o w  compared t o 10% w i t h i n  the oldest  15%  age c a t e g o r y i s a b o v e  of  68-98  the  youngest  compared t o 9 0 % w i t h i n  the oldest  the  50  age g r o u p ( 6 8 - 9 8 ) . the  percentile Conversely,  50  percentile  age c a t e g o r y .  B)AREA. TABLE XX: C r o s s t a b o f A r e a by C o m p l i a n c e Q u a r t i l e s . ( F i g u r e i n b r a c k e t s i s % of cases w i t h i n each area.) Quartile  Area 1 (Core)  1 low 2 3 4 high  4 3 4 12  (17) (13) (17) (53)  Approximately percentile of  the  53%  7 8 9 7  government  Area 4 (Farthest)  4 (33) 6 (50) 2 (17) 0  group l i v e s  5 1 1 3  (50) (10) (10) (30)  a r e above t h e 50  compared t o 40% o f t h e f a r t h e s t a n d 17%  area r e s i d e n t s .  Approximately  86%  of  the  high  i n t h e c o r e o r o u t e r - c o r e are;-"compared t o  o f t h e low c o m p l i a n c e Because  (23) (26) (29) (23)  Area 3 (Wings)  70% of t h e c o r e a r e a r e s i d e n t s  f o rcompliance  wing  compliance  Area 2 (Outer-Core)  i t i s known  group. that  the core area  housing u n i t s s p e c i f i c a l l y 77  geared  has  a  to senior  number  of  residents  an e x p l o r a t i o n o f t h e l i n k In  fact,  between age a n d a r e a was n e c e s s a r y .  t h e mean age i n t h e c o r e a r e a  i s 61.1 y e a r s  , and  49.0 y e a r s f o r t h e o u t e r - c o r e a r e a , 45.5 y e a r s f o r t h e w i n g and  50.0 f o r t h e f a r t h e s t a r e a .  Thus,  areas  the core area contains  a  p o p u l a t i o n w i t h a mean age a t l e a s t a d e c a d e g r e a t e r t h a n  f o r the  other  whether  the  areas. core  closer  T h i s makes i t v e r y d i f f i c u l t  area  to  the c l i n i c  more c o m p l i a n t To  see  g r o u p i s more c o m p l i a n t  i f age a n d a r e a  interaction  compliance.  i t is  located a  group.  area as independent  little  because  o r b e c a u s e i t i s an o l d e r a n d t h e r e f o r e  i n t e r a c t t o e f f e c t compliance  A n a l y s i s o f V a r i a n c e was p e r f o r m e d and  t o determine  Therefore,  2-Way  on t h e 76 DCHC c a s e s u s i n g age  variables.(Table XXI)Clearly,  between  a  age  and  area  area e f f e c t s compliance  in  there  is  determining  independently of  age. TABLE X X I :  ANOVA f o r Age a n d A r e a  Source of V a r i a t i o n Main E f f e c t s Age Area 2-Way I n t e r a c t i o n  w i t h Compliance  F-Value 3.0 2.3 2.0 1.2  S i g n i f i c a n c e of F .009 .070 .122 .301  C)RACE. TABLE X X I I : C r o s s t a b o f Race by C o m p l i a n c e ( F i g u r e i n b r a c k e t s i s % w i t h i n each race  Approximately  72% of Chinese 78  Quartile. category)  p a t i e n t s a t t h e DCHC a r e i n t h e  high  compliance  natives.  Conversely,  50  percentile  for  Chinese.  These  results  compliance.  was  shown  indicate  T h i s r e s u l t must be i n t e r p r e t e d  reduced  by a b o u t one t h i r d  using the c l i n i c  between  e f f e c t s of the when  28%  race  c a r e f u l l y as i t  other  of the  variable  independent  major r a c i a l  groups  we f i n d t h e mean age f o r C h i n e s e was 65.2 y e a r s ,  W h i t e s 55.5 y e a r s and f o r n a t i v e s 43.0 y e a r s .  whether  and  were a d d e d t o t h e m o d e l .  When we r e v i e w t h e age s t r u c t u r e  for  that  of  a r e below t h e  a significant relationship  i n the previous section  were  variables  76% of n a t i v e s a t t h e c l i n i c  25%  o f c o m p l i a n c e c o m p a r e d t o 38% f o r w h i t e s  and  race  q u a r t i l e compared t o 60% o f w h i t e s and  determine  b e t w e e n r a c e and age a 2-Way  ANOVA  was  p e r f o r m e d . R e s u l t s were t h e same a s t h o s e f o r age a n d  area,  that  i s no i n t e r a c t i o n e f f e c t b e t w e e n age a n d r a c e .  The  there i s interaction  To  pattern  of h o s p i t a l i z a t i o n a l s o  interacts with  race,(Table  XXI11 ) TABLE X X I I I :  Hospitalization  Hospitalization?  Chinese  Hospitalized  5  Not  2  hospitalized  hospitalized Native compared  hospitalized  RACE |  Native  6  White  19  29  4  compared t o n o n - h o s p i t a l i z e d .  category to  by R a c e .  t i m e s a s many n a t i v e s  non-hospitalized.  13  However are  within  the  hospitalized  as  The l i k l i h o o d o f a n a t i v e  being  i s t h e r e f o r e much g r e a t e r t h a n f o r t h e o t h e r  races.  N a t i v e s a r e p r o b a b l y p e r c e i v e d a s n o n - c o m p l i a n t by t h e c l i n i c i a n s 79  a t T.B. C o n t r o l and h o s p i t a l i z e d a t a g r e a t e r r a t e . 1.Medical  Variables:  A)DIAGNOSIS. TABLE X X I V : D i a g n o s i s by C o m p l i a n c e F a r Adv.  Quartile 1 low 2 3 4 high  5 5 4 11  Forty  four  percent  quartile  cases  50%  discernable, percentile advanced  it for  or  previous  of  with  minimal cases. clear  3 4 1 8  While  in  the  moderately no  real  diagnosed  According t o the  diagnosis  acts  as  pattern  is  the  50  moderately  analysis  independently  high  advanced  t h a t 74% o f t h e c a s e s a b o v e  advanced.  variables.  4 (57) 2 (29) 1 (14)  (19) (25) (6) (50)  cases are  11% o f  compliance are e i t h e r  far  Other  Minimal  of f a r advanced  compared  is  section  independent  Adv. 8- (30) 6 (22) 10(37) 3(11)  (20) (20) (16) (44)  compliance and  Mod  Quartile.  in  of  the  other  1  B)HOSPITALIZED? TABLE X X V : H o s p i t a l i z a t i o n by C o m p l i a n c e Quartile  |  Hospitalized  |~  Quartile  Not-hospital ized  1 low 2 3  16 (30) 14 (27) 10 (19)  2 (11) 3(17) 6 (33)  4 high  13 (25)  7 (39)  Fifty  three  cases  were  hospitalized, eighteen  h o s p i t a l i z e d and t h e f a t e o f f i v e c a s e s was unknown. XXV  the  percentile  proportion for  of  compliance  non-hospitalized  cases  i s almost double  the  were From above  not Table the  proportion  of  h o s p i t a l i z e d cases. In  summary, ( i n t e r m s o f  socio-demographic 80  variables)  older  50  tuberculosis b e s t as  and who have not been h o s p i t a l i z e d t e n d t o  out-patients  Conversely, Native  i n t e r m s of  younger  patients  in equal proportion)  farther  from  the c l i n i c  of  usually  had  of  i n terms of a t t e n d a n c e  treatment.  t h i s age  number of c a s e s The f i n d i n g s  g r o u p i s among t h e  Findings  compliance.  t h e age  compared  group  to  the  in t h i s chapter  also  least  compliant  for  receive this  special  chapter  attention  to  from t h e DCHC.  a l s o suggest  that  hospitalized  f a r more f r e q u e n t l y t h a n o t h e r g r o u p s  severity  diagnosis  This  to  O b v i o u s l y , t h i s group which i s mainly White or N a t i v e  C a n a d i a n - b o r n must  still  live  epidemiology  was shown i n C h a p t e r 5 t h a t  the Study A r e a .  that  and  and who have been h o s p i t a l i z e d t e n d  a disproportionate  population indicate  It  White  l e s s severe d i a g n o s i s ,  do t h e s e f i n d i n g s mean i n t e r m s of t h e T . B  the Study Area?  20-59  compliance  (these are  who have  p e r f o r m w o r s t as o u t - p a t i e n t s What  attendance  perform  of  appear may  appears'no greater  over-represented  suggest that  i n t h e low  for  Natives even  Natives.  compliance  are  though Natives  quartile.  t h e h i g h r a t e of h o s p i t a l i z a t i o n f o r  N a t i v e g r o u p may n o t h e l p a t t e n d a n c e  c o m p l i a n c e at  the  t h e DCHC.  8.4 DROP-OUTS: Of 76 DCHC c a s e s , group  which  proportion shorter as  cannot  treatment  than  for less  than 6 months.  had l e s s t h a n 6 months t r e a t m e n t  in-patients.  less  16 a t t e n d e d  6  be c o n s i d e r e d d r o p - o u t s at  t h e DCHC as  In f a c t months  5 of  the  received  the  out-patients  a  because  they  t h e y r e c e i v e d much of 16 c a s e s a t t e n d i n g an  u n i n t e r r u p t e d c h e m o t h e r a p y b e c a u s e of  82  as  Of  average their  of  45  needed  their  care  t h e DCHC f o r weeks  of  in-patient care.  This  left  9 o u t o f 76 c a s e s who c o u l d be c o n s i d e r e d  These  9  r e c o r d s were a n a l y z e d i n g r e a t e r d e t a i l  d e t e r m i n e w h e t h e r t h e y were t r u e n o n - c o m p l i n g f i v e o f t h e n i n e c a s e s moved t o o t h e r c i t i e s of  these f i v e  patient who  drop-outs.  s t a y e d i n t h e a r e a and appeared  to  i n B.C.  A follow-up  a course of  This l e f t be  t r y and  drop-outs. In fact,  r e c o r d s showed t h e y a l l c o m p l e t e d  chemotherapy a t another c l i n i c .  to  out-  four cases  drop-outs.  However,  t h r e e o f t h e s e f o u r c a s e s were d i s c o n t i n u e d f r o m t h e DCHC p r o g r a m by  physicians order.  was  such  a  One o f t h e s e was d i s c o n t i n u e d b e c a u s e  good c o m p l i e r she was a l l o w e d t o t r e a t  home. A n o t h e r  was d i s c o n t i n u e d b e c a u s e he d e v e l o p e d  she  herself renal  at  failure  and c o u l d n o t t o l e r a t e t h e d r u g s . The t h i r d c a s e was d i s c o n t i n u e d b e c a u s e he p r o v e d c o m p l e t e l y u n c o o p e r a t i v e . The who  single  received  true drop-out  was a 24 y e a r o l d V i e t n a m e s e  12 weeks o f c h e m o t h e r a p y on t h e DCHC  t h e n d i s a p p e a r e d f o r 9 months. 6 completed were  chemotherapy.  conclusion,  Two and  This  means  were  Study  A r e a d u r i n g t h e S t u d y P e r i o d was a b o u t  a drop-out.  r a t e a t t h e DCHC f o r r e s i d e n t s  83  cases  drop-outs.  one o u t o f 76 c a s e s c a n be c a l l e d  the drop-out  and  drop-outs  d i s c o n t i n u e d f r o m t h e p r o g r a m by p h y s i c i a n o r d e r  t h e r e f o r e not true non-complying In  program  Thus, of t h e 9 apparent  s u c c e s s f u l c o u r s e s o f T.B.  woman  1.5 p e r c e n t .  of t h e  Whether a p e r s o n was a l c o h o l i c had  little  o r e m p l o y e d o r unemployed  e f f e c t on c o m p l i a n c e .  Residence important  or not,  in relation  predictor.  to  the c l i n i c  I f we a n a l y z e  i s the single  most  t h e maximum d i s t a n c e o f  each  of t h e f o u r r e c o d e d a r e a s f r o m t h e DCHC i t i s e v i d e n t lies  w i t h i n a 0.5 k i l o m e t e r  1 kilometer  r a d i u s , Area 3 w i t h i n a 2 k i l o m e t e r  within a 4 kilometer It  1).  (Area  of  (Area  of  services An  93% of appointments  Alcoholism  attended  These  under study,  data  than  1 kilometer  suggest that  t h e most e f f e c t i v e  a  finding  minor f a c t o r  predicting  by  f o r the  only  skid-row  location for  clinic  was  that  attendance  alcoholism compliance.  i s a m a j o r s e l e c t i o n f a c t o r u s e d by p h y s i c i a n s a t t h e  i n t h i s study,  In view  of t h e  p h y s i c i a n s may want t o s e l e c t p a t i e n t s on predictive variables  particularly  race and a r e a .  3.The t h i r d The Older  f r o m t h e DCHC  residences.  i n t h i s study  t h e b a s i s o f some o f t h e o t h e r age,  more  9 3 % o f a p p o i n t m e n t s o r more  f o r p l a c i n g p a t i e n t s i n t h e DCHC p r o g r a m .  findings  or  0.5  o f r e s i d e n t s l o c a t e d between 0.5 a n d  i s w i t h i n 1 kilometer of c l i e n t s  as  within  t o 9 3 % o r more o f a p p o i n t m e n t s was a c h i e v e d  interesting  appears  WCC  attended  from t h e c l i n i c  residents.  population  r a d i u s and Area 4  t h a t 70% of r e s i d e n t s  2 ) . For distances greater  attendance 30%  the c l i n i c  F i f t y - t w o percent  kilometer  Area 2 w i t h i n a  r a d i u s of t h e c l i n i c .  i s c l e a r from t h e data  kilometers  1  radius of t h e c l i n i c ,  t h a t Area 1  question:  answer t o t h i s q u e s t i o n  f o l l o w s from t h e second  p e r s o n s who l i v e c l o s e t o t h e c l i n i c  diagnoses tend  to attend well.  question.  a n d have more  severe  I f the older person i s Chinese or 85  patients  tend  younger  to  benefit  clients least.  increasing  most  of  compliance  Although a socio-demographic  to  the c l i n i c  a c t s i n d e p e n d e n t l y of age  compliance. Location i n r e l a t i o n potent socio-demographic  to the c l i n i c  variable effecting  than i t r e a l l y  the  have  area  interesting  to  hospitalized Chinese  unique  g r a d i e n t of  note  that  compared  in  of  may  It  Native  to r e s p e c t i v e l y  of  compliance.  structures. 86%  DCHC,  terms  appear  i s because the t h r e e r a c i a l age  and  i s t h e s i n g l e most  r a c e and h o s p i t a l i z a t i o n a r e l i n k e d . Age  significant  is  T.B.  more  groups  particularly patients  67% o f W h i t e  in  and  71%  are of  patients.  I t may  be t h a t c l i n i c i a n s a t t h e T.B.  more  non-compliant  than  other r a c i a l groups.  tend  to  severity  and  D i v i s i o n v i e w n a t i v e s as  tend to h o s p i t a l i z e Another  them more  possiblility  p r e s e n t w i t h more s e v e r e d i a g n o s e s  hospitalization.  White  terms  age c o i n c i d e s w i t h i n c r e a s i n g p r o x i m i t y t o t h e  proximity  Age,  in  However,  reference  (63%  of  N a t i v e s have  d i a g n o s e s compared t o 80% o f  i s that  thereby  Natives requiring  t o T a b l e XXVI  of d i a g n o s i s among N a t i v e s a p p e a r s  group.  frequently  shows  l e s s t h a n among  moderate  or  that the  far-advanced  Whites)  TABLE X X V I : C r o s s t a b u l a t i o n o f Race and D i a g n o s i s . Far-adv.  RACE Nat i v e White Chinese  Minimal  Other  6  (27%)  8  (36%)  3  (14%)  5  (23%)  17  (41%)  16  (39%)  7  (17%)  1  (3%)  2  (29%)  1  (14%)  3  (42%)  1  (14%)  In g e n e r a l , the c l i n i c  Mod.-adv.  who  o l d e r White  o r C h i n e s e p a t i e n t s who  live close  have been d i a g n o s e d w i t h f a r - a d v a n c e d o r 81  to  moderate  RECOMMENDATIONS To  i n c r e a s e t h e e f f e c t i v e n e s s of t h e DCHC, T.B.  must  know  That  is,  living  who  Canadian-born  at  a  attention. the  i s at high r i s k  be  route  the  enhanced t h e T.B.  beyond  Abbot  waterfront). contact  younger  to  give  nurse  and  Heatley  t h e young a t - r i s k  of  that planners  population. services address are  the  receive  special nurse  special  (which  group l i v i n g  of  r e g u l a r home-  extend  roughly and  compliance,  This  means this  t h a t any  r a p i d change and may  'follow'  in relation  tubercular  areas  be  of  based  to  of  the  important  population  tuberculosis on  flux,  satellite  to  skid-row  accurate  l i k e Vancouver's  p o p u l a t i o n s as t h e y  87  because  i t is very  the  have t o e s t a b l i s h  skid-row  from  s e r v i c e s very c l o s e l y  must  For skid-row  clinic  at a distance  development  population  information.  planners  for  the  skid-row.  of r e s i d e n c e  residence  at  attention.  c u r r e n t urgency  underway on  importance  area  for  essentially  must  this  locate out-patient c l i n i c  undergoing  control  those  S t r e e t and H a s t i n g s  T h i s e x p a n d e d r o l e has  i n terms of a t t e n d a n c e  main  (particularly  needs t o expand her  l o c a l Expo-86 r e l a t e d u p h e a v a l s  the  DCHC.  T h i s i s l i k e l y a good method of m a i n t a i n i n g  DCHC.  clinic  clinic)  current boundaries  Street  with  Because  patients  staff  the  I t i s recommended t h a t t h e r o l e of t h e T.B.  Specifically,  between  f o r non-compliance at  d i s t a n c e from the  clinic  visit  Division  which  tuberculosis clinics  relocate.  to  REFERENCES 1. A n d r e w s , F.M., K l e m , L., Davidson, T.N., O'Malley, P.M., R o d g e r s , W.L., A Guide f o r S e l e c t i n g S t a t i s t i c a l Techniques for A n a l y z i n g S o c i a l S c i e n c e D a t a . Ann Arbor, Michigan, U n i v e r s i t y of M i c h i g a n , 1981. 2. B a h r , H.M., "The G r a d u a l D i s a p p e a r a n c e of S k i d - R o w . " P r o b l e m s ,15:41-45, 1967.  Social  3. B a k a n , R. , R e p o r t on t h e H e a l t h S t a t u s of C e n s u s T r a c t s 57, 58, and 59, City of Vancouver H e a l t h and Planning D e p a r t m e n t s , December, 1978. 4.  B a r n e t t , G.D., G r z y b o w s k i , S., S t y b l o , K., " P r e s e n t R i s k of Developing A c t i v e T u b e r c u l o s i s i n Saskatchewan A c c o r d i n g to Previous T u b e r c u l l i n and X-Ray S t a t u s . " B u l l e t i n of t h e I n t e r n a t i o n a l U n i o n f o r T u b e r c u l o s i s , 45:51-74, 1971.  5. B e c k e r , M.H., Drackman, R.H., K i r s c h t , J . P . , " M o t i v a t i o n s as Predictors of H e a l t h B e h a v i o u r . " H e a l t h S e r v i c e s Reports. 87:852-862, 1972. 6.  Bogue, D.J., Skid-Row i n A m e r i c a n C i t i e s . C h i c a g o , U n i v e r s i t y of C h i c a g o P r e s s , 1963.  7. Canada, R o y a l C o m m i s s i o n on H e a l t h S e r v i c e s : T u b e r c u l o s i s Canada. O t t a w a , Queen's P r i n t e r , 1964. 8. C a s t i g l i o n i , A., H i s t o r y of T u b e r c u l o s i s . New L i f e Press, 1933. 9. Chao, C.W.,  "Personal  C o m m u n i c a t i o n . " May,  York,  in  Medical  1985.  10. Chapman, J . S . , D y e r l y , M.D. " S o c i a l and O t h e r F a c t o r s i n t h e inter-familial transmission of t u b e r c u l o s i s . " American R e v i e w of R e s p i r a t o r y D i s e a s e , 80:48, 1964. 11. C h a v e s , A.D., Robins, A.B., A b e l e s , H. "T.B. Case Finding Among H o m e l e s s Men i n New Y o r k C i t y . " A m e r i c a n R e v i e w of R e s p i r a t o r y D i s e a s e . 87:102-104, 1961. 12. C o m s t o c k , G.W. P r e v e n t i v e M e d i c i n e and York, Appleton-Century-Crofts, 1973.  Public Health.  13. C o o k e , N . J . "Treatment of T u b e r c u l o s i s . " B r i t i s h J o u r n a l ,291:497-498, 1985.  New  Medical  14. D a n i e l , T.M., " S e l e c t i v e Primary Health Care: S t r a t e g i e s f o r Control of Disease i n the Developing World, II: Tuberculosis."Reviews of I n f e c t i o u s D i s e a s e s ,6:1254-1265, 1 982. 15. D e v i ,  S.,  "A  C o n t r o l l e d Comparison 88  of  Self-Administered  CHAPTER 9 CONCLUSIONS AND RECOMMENDATIONS. CONCLUSIONS. This  thesis  set  community-based (in  terms  system  attendance  the  demographic at  out-patient  of  at  out t o examine t h r e e q u e s t i o n s :  WCC  for  skid-row  1. The f i r s t  factors  DCHC,  which  tuberculosis attendance  to o u t - p a t i e n t  represents  treatment  2 . The s e c o n d  younger better  from  t h e DCHC has s i g n i f i c a n t l y t h a n t h e WCC when  the l a t e s t  appears  patients.  developments  to  promote  in  better  t h a n t h e WCC.  t h e DCHC i s a s i g n i f i c a n t approach for skid-row  The  improvement patients.  question:  age,  diagnosis  and r a c e  p r e d i c t i n g attendance closest  who  socio-  compliance  skid-row tuberculosis  one o f  over the former h o s p i t a l - b a s e d  those  Which  and who does n o t b e n e f i t  c o m p l i a n c e among s k i d - r o w p a t i e n t s  live  better  hospital-based  2)  appointments  systems  community-based approach at  who  the  p r e d i c t attendance  compliance,  c o m p a r i n g a matched p o p u l a t i o n o f  factors  t h e DCHC  the  question:  attendance  Area,  than  Is  system.  I n t e r m s of a t t e n d a n c e  The  system at  patients?  and ; 3) Who b e n e f i t s  t h e new t r e a t m e n t  greater  compliance)  and t r e a t m e n t  t h e DCHC?  treatment  1)  live  patients. than those  attend better  compliance at  to the c l i n i c far  away.  Persons with less  (in that  order) the  w i t h more  attend  severe  severe diagnoses.  main  Patients  better  than  better  than  diagnoses  attend  In g e n e r a l ,  Chinese  t h a n W h i t e s who i n t u r n a t t e n d b e t t e r  84  the  DCHC.  attend appointments  Older patients  are  than N a t i v e s .  V e r s u s S u p e r v i s e d Treatment i n Singapore." B u l l e t i n of t h e I n t e r n a t i o n a l Union f o r Tuberculosis,47:15-21, 1972. 16. Dubos, J . , Dubos, R.,The W h i t e P l a g u e . and Co., 1952.  Boston, L i t t l e  Brown  17. D u t t , A.R., Jones, L . J . , Stead, W.W., "Short-Course Chemotherapy f o r T u b e r c u l o s i s W i t h Twice-Weekly I s o n i a z e d and R i f a m p i c i n . " C h e s t ,75:441-447, A p r i l , 1979. 18. E a s t - A f r i c a n B r i t i s h M e d i c a l R e s e a r c h C o u n c i l , " C o n t r o l l e d T r i a l s o f S h o r t - C o u r s e (6 month) Regimens o f C h e m o t h e r a p y for Treatment o f P u l m o n a r y T u b e r c u l o s i s . " L a n c e t ,10791085, 1972. 19. E n a r s o n , D.A., Sjogren, I . , G r z y b o w s k i , S., " I n c i d e n c e o f Tuberculosis Among S c a n d a n a v i a n Immigrants i n Canada." E u r o p e a n J o u r n a l o f R e s p i r a t o r y D i s e a s e ,61:139-142, 1980. 20.  E n a r s o n , D.A., " A c t i v e T u b e r c u l o s i s i n I n d o - C h i n e s e R e f u g e e s i n B . C . . " C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l ,131:39-42, 1984.  21. E n a r s o n , D.A., "Personal C o m m u n i c a t i o n . " An r e p o r t on t u b e r c u l o s i s i n V a n c o u v e r , 1984. 22.  E n a r s o n , D.A.,  "Personal  Communication." February,  unpublished 1986.  23. E n g l e , A., R o b e r t s , J . , T u b e r c u l i n S k i n T e s t R e a c t i o n Among Adults 25-74 Y e a r s , United States, 1971-72. National H e a l t h S u r v e y , s e r i e s I I , no.204, P u b l i c a t i o n No. (HRA) 771649. U.S. D e p a r t m e n t o f H e a l t h , E d u c a t i o n a n d W e l f a r e , W a s h i n g t o n , D.C., 1977. 24.  F o x , W., " C o m p l i a n c e o f P a t i e n t s a n d P h y s i c i a n s : E x p e r i e n c e and Lessons from T u b e r c u l o s i s : II." British Medical J o u r n a l ,287:101-105, 1983.  25. H o l l a n d e r , M., W o l f e , D.A., N o n p a r a m e t r i c Statistical M e t h o d s . New Y o r k , L o n d o n , S y d n e y , T o r o n t o , 1973. 26.  Horwitz, 0., " T u b e r c u l o s i s Risk and M a r i t a l Status." A m e r i c a n R e v i e w o f R e s p i r a t o r y D i s e a s e ,104:222-31, 1971.  27. Hong-Kong T u b e r c u l o s i s Treatment Survey/ B r i t i s h Medical Research Council, "Controlled Trial o f 6 a n d 9 Month Regimens of D a i l y and I n t e r m i t t e n t S t r e p t o m y c i n , Plus I s o n i a z i d , P l u s P y r a z i n a m i d e f o r Pulmonary T u b e r c u l o s i s i n H o n g - K o n g . " T u b e r c u l e ,56:81-96, 1975. 28.  J a n g , K., "A C o m p a r i t i v e E v a l u a t i o n o f H o s p i t a l V e r s u s C l i n i c Education of Tuberculosis Patients in Vancouver." Unpublished Masters Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1978.  89  W h i t e he/she w i l l more l i k e l y Younger clinic)  patients  dominate  a t t e n d b e t t e r than a N a t i v e person.  (especially  t h o s e who l i v e  f a r from  t h e ranks of t h e low c o m p l i a n c e q u a r t i l e .  the These  p a t i e n t s t e n d t o be W h i t e o r N a t i v e i n a b o u t e q u a l p r o p o r t i o n . Another  purpose  epidemiological showed  that  hundred 375  data  Study  thousand  per  hundred  to  the  thesis  on t u b e r c u l o s i s A r e a r a t e s were  was  to  these,  some  This  study  i n skid-row. i n the region  of  and r a t e s  i n t h e Downtown-Eastside  thousand  during  t h e Study  4 0 % were N a t i v e a n d 60% n o n - N a t i v e .  250 p e r approached  Period.  i n d i c a t e t h a t 60% o f c a s e s i n t h e S t u d y A r e a were Of  gather  Results  Canadian-born. The f o r e i g n - b o r n  h i g h - r i s k group r e p r e s e n t e d 40% of c a s e s i n t h e a r e a . Rates  i n t h e Study Area appear  relatively  mix o f c a s e s among t h e 3 h i g h - r i s k g r o u p s . rapidly fairly the  s t a b l e a s does t h e  However,  the area i s  d e p o p u l a t i n g due t o Expo-86 r e l a t e d d e v e l o p m e n t s s t a b l e a b s o l u t e numbers may i n d i c a t e  increasing  so t h a t  rates  in  Study A r e a . Sixty  p e r c e n t o f c a s e s i n t h e a r e a were  Canadian-born.  This  group r e p r e s e n t s t h e m a j o r i t y of cases i n t h e a r e a . Canadian-born persons treat'  a r e a l s o more l i k e l y group  t o belong  r e f e r r e d t o t h e DCHC.  to  Once r e f e r r e d  Canadian-born  persons a r e a t h i g h e s t r i s k  appointments.  Thus,  the Canadian-born  require particular attention  the  'difficult-toto  DCHC  f o r non-compliance  cases i n t h e Study  i n terms of t u b e r c u l o s i s  86  the  to Area  control.  29.  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