Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1986_A6_7 O87.pdf [ 5.51MB ]
Metadata
JSON: 831-1.0096764.json
JSON-LD: 831-1.0096764-ld.json
RDF/XML (Pretty): 831-1.0096764-rdf.xml
RDF/JSON: 831-1.0096764-rdf.json
Turtle: 831-1.0096764-turtle.txt
N-Triples: 831-1.0096764-rdf-ntriples.txt
Original Record: 831-1.0096764-source.json
Full Text
831-1.0096764-fulltext.txt
Citation
831-1.0096764.ris

Full Text

EVALUATION OF A COMMUNITY BASED OUT-PATIENT TREATMENT PROGRAM FOR TUBERCULAR PATIENTS RESIDENT IN DOWNTOWN DISTRICTS OF VANCOUVER By ALECK SAMUEL OSTRY B . S c , The U n i v e r s i t y of B r i t i s h Columbia, 1976. A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (HEALTH SERVICES PLANNING AND ADMINISTRATION) i n THE FACULTY OF GRADUATE STUDIES (Department of H e a l t h Care and E p i d e m i o l o g y ) We accept t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA May, 1986 ( c ) A l e c k Samuel O s t r y , 1986 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e 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 , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e 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 c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my 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 . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l 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 p e r m i s s i o n . D e p a r t m e n t o f H E A L T H CARE AND EPIDEMIOLOGY. 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 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 Date A P R I L 23 r d /1986. 7Q ^  i i ABSTRACT T h i s study i s an e v a l u a t i o n ( i n terms of attendance compliance) of the community based t u b e r c u l o s i s o u t - p a t i e n t program a t the Downtown Community H e a l t h C l i n i c (DCHC) i n Vancouver. Treatment compliance i s a measure of the degree of adherence t o a treatment regime 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 compliance i s concerned o n l y w i t h a t tendance t o c l i n i c a ppointments. Because treatment a t the DCHC i s s u p e r v i s e d , attendance compliance can be c l o s e l y a s s o c i a t e d w i t h t r eatment c o m p l i a n c e . The DCHC was e s t a b l i s h e d i n Vancouver's Downtown-Eastside d i s -t r i c t i n 1980 i n an e f f o r t t o reduce t u b e r c u l o s i s r a t e s among the skid - r o w p o p u l a t i o n . P r i o r t o 1980, skid-row p a t i e n t s were r e q u i r e d t o a t t e n d the W i l l o w Chest C l i n i c (WCC), l o c a t e d o u t s i d e the downtown a r e a . P r i o r t o 1979, h o s p i t a l - b a s e d o u t - p a t i e n t t h e r a p y a t the WCC l a s t e d 18-24 months and was u n s u p e r v i s e d . Community-based treatment a t the DCHC g e n e r a l l y l a s t s 9 months. Treatment i s s u p e r v i s e d by a t u b e r c u l o s i s nurse a t the DCHC who p l a y s a key r o l e i n promoting c o m p l i a n c e . The e v a l u a t i o n i s based on a comparison of attendance t o appointments a t both these c l i n i c s . As background f o r the e v a l u a t i o n , a model of t u b e r c u l o s i s e p i d e m i o l o g y i n developed c o u n t r i e s i n g e n e r a l and Canada i n p a r t i c u l a r i s d e s c r i b e d . The model shows t h a t as t u b e r c u l o s i s r a t e s have f a l l e n , t h r e e main groups a t h i g h - r i s k f o r the d i s e a s e have emerged; a b o r i g i n a l p e o p l e , immigrants from c o u n t r i e s w i t h h i g h r a t e s , and non-Native r e s i d e n t s of urban s k i d - r o w d i s t r i c t s . These t h r e e groups are w e l l r e p r e s e n t e d i n Vancouver's skid-row i i i d i s t r i c t s and ac c o u n t f o r most of t h e p a t i e n t p o p u l a t i o n a t t h e 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 t r e a t m e n t s t r a t e g i e s have e v o l v e d i n r e l a t i o n t o t e c h n o l o g i c a l d evelopments and t h e c h a n g i n g e p i d e m i o l o g y of t u b e r c u l o s i s i n d e v e l o p e d c o u n t r i e s . The a d a p t a t i o n of modern t u b e r c u l o s i s t r e a t m e n t methods i n B.C. and Vancouver i s t r a c e d , c u l m i n a t i n g w i t h t h e development of h o s p i t a l based o u t - p a t i e n t t r e a t m e n t a t the WCC and community based o u t -p a t i e n t t r e a t m e n t a t t h e DCHC. The 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 V a n c o u v e r ' s s k i d - r o w i s the n d e s c r i b e d i n r e l a t i o n t o the s o c i o - d e m o g r a p h i c c o n d i t i o n s of t h e a r e a . The w e l l 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 and p o v e r t y i s d i s c u s s e d . S o c i o - d e m o g r a p h i c u p h e a v a l s i n the a r e a r e l a t e d t o Va n c o u v e r ' s 1986 W o r l d s F a i r a r e d e s c r i b e d and t h e i r p o s s i b l e 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 p r o blem o u t l i n e d . T h i s b a c k g r o u n d , which o u t l i n e s t h e socio-demography of t h e t u b e r c u l a r p o p u l a t i o n and shows the r a t i o n a l e b e h i n d t h e i r t r e a t -ment system ( a t the DCHC), s e t s t h e s t a g e f o r a d i s c u s s i o n on c o m p l i a n c e . T u b e r c u l a r p a t i e n t s must t a k e d r u g s r e g u l a r l y f o r a l o n g p e r i o d of t i m e . T h i s r e q u i r e s a l e n g t h y and d i s c i p l i n e d i n t e r a c t i o n w i t h t h e t r e a t m e n t system. For the g e n e r a l l y poor and o f t e n a l i e n a t e d t u b e r c u l a r p o p u l a t i o n on s k i d - r o w , t h i s may pose p a r t i c u l a r d i f f i c u l t i e s . A t t e n d a n c e t o c l i n i c a p p o i n t m e n t s i n o r d e r t o r e c e i v e d r u g s may be the s i n g l e most i m p o r t a n t f a c t o r i n a s u c c e s s f u l t r e a t m e n t outcome. W i t h t h e p i v o t a l r o l e of a t t e n d a n c e c o m p l i a n c e e s t a b l i s h e d , major s o c i o - d e m o g r a p h i c f a c t o r s p r e d i c t i v e f o r a t t e n d a n c e i v c ompliance a t the DCHC are determined and the DCHC i s e v a l u a t e d by comparing i t ' s a b i l i t y t o promote attendance compliance w i t h the WCC. 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 i n the e v a l u a t i o n comparing the DCHC c l i e n t s f o r the y e a r s 1981-83 w i t h matched c o n t r o l s who a t t e n d e d the WCC i n the y e a r s 1977-79. R e s u l t s of the e v a l u a t i o n i n d i c a t e attendance compliance of p a t i e n t s a t the DCHC was s i g n i f i c a n t l y b e t t e r than a t the WCC. Furthermore, f o u r major f a c t o r s p r e d i c t i v e f o r compliance were i d e n t i f i e d . These were, i n orde r of importance, p a t i e n t ' s address i n r e l a t i o n t o the c l i n i c , p a t i e n t ' s age, s e v e r i t y of d i a g n o s i s and r a c e . V TABLE OF CONTENTS PAGE ABSTRACT i i TABLE OF CONTENTS v LIST OF TABLES v i i LIST OF FIGURES i x ACKNOWLEDGEMENTS x CHAPTER 1 INTRODUCTION 1 .1 Overview 1 1.2 The Q u e s t i o n s 3 1.3 T h e s i s S t r u c t u r e 4 CHAPTER 2 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 Developed N a t i o n s . . . 7 2.3 The Cohort E f f e c t 10 CHAPTER 3 THE EVOLUTION of TUBERCULOSIS TREATMENT 3.1 I n t r o d u c t i o n 13 3.2 Pre-Modern E r a of T.B. Treatment... 13 3.3 Modern E r a of T.B. Treatment 14 1 . S u r g i c a l Treatment 14 2 . S a n i t o r i a 15 3 . Chemotherapy 17 CHAPTER 4 TUBERCULOSIS CONTROL IN B.C. 4.1 The E a r l y Years 25 4.2 The D i v i s i o n of T.B. C o n t r o l .25 4.3 The W i l l o w Chest C l i n i c 28 4.4 The Downtown Community C l i n i c 29 CHAPTER 5 EPIDEMIOLOGY and SOC IO-DEMOGRAPHY i n the STUDY AREA 5.1 I n t r o d u c t i o n 32 5.2 T.B.Epidemiology i n the Study Area.32 5.3 Socio-demography of the Study Area.38 5.4 The High R i s k Groups 42 CHAPTER 6 COMPLIANCE 6.1 Compliance and Socio-demography....48 6.2 Attendance Compliance 50 v i TABLE OF CONTENTS ( c o n t ' d ) CHAPTER 7 THE EFFECT OF TWO TYPES OF CLINIC 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 Boundaries 55 7.3 The V a r i a b l e s 56 1. Independent 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 Coding 58 7.5 B i a s 61 7.6 Study Design 1 . Q u e s t i o n 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) Matching 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 'Drop-outs' 65 CHAPTER 8. THE EFFECTS OF TWO TYPES OF CLINIC SYSTEMS ON COMPLIANCE TO T.B. CHEMOTHERAPY. RESULTS AND DISCUSSION: 8. 1 Q u e s t i o n 1 67 8.2 Q u e s t i o n 2 71 8.3 Q u e s t i o n 3 76 8.4 'Drop-outs' 82 CHAPTER 9 CONCLUSIONS AND RECOMMENDATIONS 84 REFERENCES 88 APPENDICES 92 Appendix A Map of N o r t h H e a l t h U n i t and Study Area....93 Appendix B Map of Recoded Areas 94 v i i LIST OF TABLES PAGE Ta b l e I : T.B. Death Rate i n B.C. and Canada 18 Tab l e I I : S a n a t o r i a P o p u l a t i o n i n B.C. (1952-64) 26 T a b l e I I I : Percentage of T.B. O u t - p a t i e n t s a t the WCC . . 2 8 T a b l e IV: Comparison of I n c i d e n c e Rates i n B.C., Metro-Vancouver, the Nor t h H e a l t h U n i t , the Study Area and Census T r a c t 58 d u r i n g the Study P e r i o d 32 T a b l e V: Comparison of the Mean Rates i n B.C., Metro-Vancouver, the Nor t h H e a l t h U n i t , the Study Area and Census T r a c t 58 d u r i n g the Study P e r i o d 33 T a b l e V I : Percentage of Canadian-born and non-Canadian-born Persons i n the Study Area and Census T r a c t 58 D u r i n g the Study P e r i o d 35 T a b l e V I I : P e r c e n t a g e of N a t i v e and non-Native Canadian-born Cases i n the Study Area and Census 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 VI 1 1:Socio-demographic D i s t r i b u t i o n of Study Area T.B. Cases R e g i s t e r e d i n the Years 1977-79 & 1981 -83 45 T a b l e IX: Socio-demographic C h a r a c t e r i s t i c s of WCC and DCHC P a t i e n t s f o r the P e r i o d 1981-83 48 T a b l e X: Treatment S t a t u s of T.B. Cases i n the Study Area D u r i n g the Study P e r i o d 55 T a b l e X I : Wilcoxon S i g n e d Rank Test f o r Matched Data....67 T a b l e X I I : Mean Ages i n the C o n t r o l , E x p e r i m e n t a l and Unmatched Groups by Race 68 T a b l e X I I I : T o t a l Treatment Length f o r Matched H o s p i t a l i z e d Cases a t the WCC and DCHC 69 T a b l e XIV: Comparison of 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 the DCHC and WCC 70 T a b l e XV: On^vray A n a l y s i s of V a r i a n c e f o r Independent V a r i a b l e s 72 T a b l e XVI: 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 (MCA) f o r Major Independent V a r i a b l e s 73 v i i i LIST OF TABLES ( c o n t ' d ) PAGE Table XVII:MCA Table Showing D e v i a t i o n s from Compliance Mean 74 Table XVIII:Mean Compliance by Recoded Age Category 75 Table XIX: C r o s s t a b u l a t i o n of Age Category by Compliance Q u a r t i l e s 77 Table X X : C r o s s t a b u l a t i o n of Area by Compliance Q u a r t i l e s . 7 7 Table XXI: 2-Way ANOVA by Age and Area f o r Compliance...78 Table X X I I : C r o s s t a b u l a t i o n of Race by Compliance Q u a r t i l e s 79 Table X X I I I : C r o s s t a b u l a t i o n of H o s p i t a l i z a t i o n by Race...79 Table XXIV: C r o s s t a b u l a t i o n of D i a g n o s i s by Compliance Q u a r t i l e s 80 Table X X V : C r o s s t a b u l a t i o n of H o s p i t a l i z a t i o n by Compliance Q u a r t i l e s 80 Table XXVI : C r o s s t a b u l a t i o n of Race by D i a g n o s i s 81 i x LIST OF FIGURES PAGE FIGURE 1 G e n e r a l Model of T u b e r c u l o s i s Epidemiology..8 FIGURE 2 Becker's H e a l t h B e l i e f Model 50 X ACKNOWLEDGEMENTS I want t o acknowledge the c o o p e r a t i o n h e l p and support of key people and o r g a n i z a t i o n s i n the p r e p a r a t i o n and development of t h i s t h e s i s . I am g r a t e f u l t o the M i n i s t r y of H e a l t h and 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 f o r g i v i n g t h e i r a p p r o v a l f o r t h i s s t u d y . In t h i s r e g a r d I would p a r t i c u l a r l y l i k e t o thank the D i r e c t o r of T.B. C o n t r o l , Dr. E. A l l e n . Everyone a t the D i v i s i o n of T.B. C o n t r o l was v e r y h e l p f u l and q u i c k 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 would p a r t i c u l a r l y l i k e t o thank Dr. C. Chao and Ms. P. L e n t i the T.B. nurse o n - s i t e a t the Downtown Community C l i n i c . L a s t , but not l e a s t , I want t o thank my t h e s i s committee c o n s i s t i n g of Dr. D. Enarson, Dr. R. M a t h i a s and Dr. N. M o r r i s o n . My committee was e f f i c i e n t and s u p p o r t i v e . Most i m p o r t a n t l y f o r me, I l e a r n e d a l o t and developed new s k i l l s from t h e i r e f f e c t i v e t u t e l a g e . F i n a l l y , I want t o g i v e s p e c i a l thanks to Dr. M o r r i s o n f o r her p e r c e p t i v e t e a c h i n g and s u s t a i n e d support which went beyond the c a l l of d u t y . CHAPTER 1. INTRODUCTION 1.1 OVERVIEW: Over the past f i f t y y e ars the p r e v a l e n c e and i n c i d e n c e of t u b e r c u l o s i s i n developed c o u n t r i e s has d e c l i n e d d r a s t i c a l l y . T u b e r c u l o s i s , once a wide-spread d i s e a s e i n i n d u s t r i a l i z e d c o u n t r i e s , has been l i m i t e d t o w e l l d e f i n e d h i g h - r i s k groups o f t e n l o c a t e d i n urban c e n t r e s . A l t h o u g h the d i s e a s e has been l o c a l i z e d and c o n t a i n e d i n developed c o u n t r i e s , t u b e r c u l o s i s i n c i d e n c e and p r e v a l e n c e r a t e s can rea c h l e v e l s found i n d e v e l o p i n g c o u n t r i e s among these h i g h - r i s k groups. Some of the groups most a t r i s k i n developed n a t i o n s a re immigrants from c o u n t r i e s w i t h h i g h T.B. r a t e s and s o c i a l l y m a r g i n a l o f t e n a l c o h o l i c men l i v i n g i n " s k i d - r o w " a r e a s of c i t i e s . In Canada, t h e r e i s a t h i r d h i g h - r i s k group, t h a t i s a b o r i g i n a l p e o p l e s . In Vancouver, a l l t h r e e h i g h - r i s k groups are p r e s e n t . Moreover, i n the Downtown Core, Downtown-Eastside and S t r a t h c o n a * d i s t r i c t s which a r e c o n t i g u o u s w i t h census t r a c t s 57, 58 and 59 p a r t s of these communities o v e r l a p and c o - e x i s t . The Study Area i s among the p o o r e s t i n Vancouver and a c c o r d i n g t o Dr. J . B l a t h e r w i c k of the C i t y H e a l t h Department, " T h i s area has the 43 h i g h e s t i n c i d e n c e of t u b e r c u l o s i s i n B.C." A mass s c r e e n i n g program i n the Study Area c a r r i e d out i n the S p r i n g of 1985 unde r s c o r e d the magnitude of the t u b e r c u l o s i s problem i n the a r e a . E i g h t new-active cases of t u b e r c u l o s i s 22 were d e t e c t e d a f t e r s c r e e n i n g 1276 Downtown r e s i d e n t s . T h i s means *From now on t h i s a rea i s r e f e r r e d t o as the 'Study A r e a ' . 1 the p r e v a l e n c e r a t e among the screened p o p u l a t i o n was 627 per hundred thousand. A l t h o u g h t h i s a r ea has h i g h t u b e r c u l o s i s r a t e s compared to the r e s t of B.C. the h i g h r i s k group, skid-row r e s i d e n t s , have yet to be s t u d i e d i n Vancouver and the 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 the area remains r e l a t i v e l y u n e x p l o r e d . T h i s t h e s i s i s p a r t i a l l y an attempt t o c o n t r i b u t e u n d e r s t a n d i n g t o the e p i d e m i o l o g y of t u b e r c u l o s i s among t h i s h i g h r i s k group. In 1980, i n an e f f o r t t o reduce t u b e r c u l o s i s r a t e s s p e c i f i c a l l y among the skid-row p o p u l a t i o n , the B.C. 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 e s t a b l i s h e d a community based t u b e r c u l o s i s o u t - p a t i e n t treatment program a t the Downtown Community H e a l t h C l i n i c . P r i o r to 1980, s k i d 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 h o s p i t a l -based treatment program a t the W i l l o w Chest Centre a t Vancouver G e n e r a l H o s p i t a l (VGH) which i s s i t u a t e d about 5 k i l o m e t e r s from the h e a r t of the Study A r e a . The e v o l u t i o n of community-based o u t - p a t i e n t c l i n i c s l i k e the DCHC r e p r e s e n t a new t r e n d i n t u b e r c u l o s i s treatment r e s e a r c h . T r a d i t i o n a l l y , t u b e r c u l o s i s o u t - p a t i e n t chemotherapy i s h o s p i t a l -based, p r o l o n g e d (18-24 months), u n s u p e r v i s e d , and r e q u i r e s the i n g e s t i o n of two or t h r e e drugs on a d a i l y b a s i s . However, a t the DCHC, treatment l e n g t h i s s h o r t e r ( u s u a l l y 9 months), community-based, s u p e r v i s e d , and f o r most p a t i e n t s chemotherapy o c c u r s t w i c e weekly r a t h e r than d a i l y . ( S u p e r v i s s d d i f f e r s from u n s u p e r v i s e d treatment m a i n l y because i n the former case the c a r e - g i v e r watches the p a t i e n t i n j e s t the drugs so t h a t t h e r e i s a b s o l u t e c e r t a i n t y t h a t the p a t i e n t has s u c c e s s f u l l y taken 2 t r e a t m e n t . ) S h o r t e n i n g l e n g t h of t r e a t m e n t , b a s i n g the c l i n i c i n the community, and s u p e r v i s i n g m e d i c a t i o n s are treatment f a c t o r s geared p r i m a r i l y t o improving c o m p l i a n c e t o the drug regime. T h i s i s p a r t i c u l a r l y important f o r p a t i e n t s such as skid-row r e s i d e n t s who may be a l c o h o l i c , poor and a l i e n a t e d . For these p a t i e n t s e n s u r i n g f o l l o w - u p and att e n d a n c e compliance may be the most important f a c t o r i n s u c c e s s f u l t r e a t m e n t outcome. I t must be s t r e s s e d t h a t i n t h i s t h e s i s , the dependant v a r i a b l e i s attendance compliance as opposed t o treatment c o m p l i a n c e . For the DCHC, because treatment i s s u p e r v i s e d , attendance t o appointments can be c l o s e l y l i n k e d t o s u c c e s s f u l i n j e s t i o n of drugs. However, f o r the WCC, where treatment i s not s u p e r v i s e d , attendance t o appointments i s o n l y an i n d i c a t i o n t h a t drugs have been p i c k e d - u p . There i s no way to determine whether . WCC p a t i e n t s a c t u a l l y take the m e d i c a t i o n s once they go home. A major o b j e c t i v e of t h i s t h e s i s i s t o e v a l u a t e the DCHC i n terms of attendance compliance because w i t h h i g h r a t e s of t u b e r c u l o s i s among r e s i d e n t s of ski d - r o w i t i s i m p e r a t i v e t h a t e f f e c t i v e treatment i s a v a i l a b l e . 1.2 THE QUESTIONS: Three p r i m a r y q u e s t i o n s a r e addresed i n t h i s t h e s i s : 1)Is the new o u t - p a t i e n t treatment a t the DCHC b e t t e r than the o l d o u t -p a t i e n t treatment a t the WCC i n terms of compliance? 2) Which socio-demographic and treatment f a c t o r s p r e d i c t compliance a t the DCHC? and; 3) Who b e n e f i t s and who doesn't b e n e f i t from the new treatment system? The answers t o thes e q u e s t i o n s w i l l determine whether the DCHC i s e f f e c t i v e i n terms of compliance and i f so 3 they w i l l p r o v i d e d i r e c t i o n on how t o f u r t h e r improve compliance to t r e a t m e n t . 1.3 THESIS STRUCTURE: Chapter 2 i s an i n t r o d u c t o r y d i s c u s s i o n of t u b e r c u l o s i s p a t h o g e n e s i s , and g e n e r a l t u b e r c u l o s i s e p i d e m i o l o g y . The d i s c u s s i o n i s focused on t u b e r c u l o s i s e p i d e m i o l o g y i n developed c o u n t r i e s . Chapter 3 i s a d i s c u s s i o n of t u b e r c u l o s i s t r e a t m e n t . The h i s t o r y of t u b e r c u l o s i s treatment i s o u t l i n e d t o show the e v o l u t i o n away from i n - p a t i e n t c a r e towards o u t - p a t i e n t t r e a t m e n t . The development of community-based and h o s p i t a l - b a s e d o u t - p a t i e n t treatment systems f o r t u b e r c u l o s i s i s o u t l i n e d . Chapter 4 focuses the g e n e r a l treatment d i s c u s s i o n from c h a p t e r 2 onto B.C. and 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 of the WCC and DCHC. In Chapter 5, the e p i d e m i o l o g y and socio-demography of the Study Area i s d e s c r i b e d . A g a i n s t t h i s background a p r o f i l e of the h i g h - r i s k group l i v i n g i n the Study Area i s s k e t c h e d . Chapter 6 l o o k s a t compliance and d e s c r i b e s the r a t i o n a l e behind s e l e c t i o n of dependent v a r i a b l e s used i n the study. Chapter 7 i s the Methodology S e c t i o n . R e s u l t s and d i s c u s s i o n a r e p r e s e n t e d i n Chapter 8. C o n c l u s i o n s and recommendations a r e i n Chapter 9. In o r d e r t o o r i e n t the reader and as p a r t of the t h e s i s o u t -l i n e , the geographic and temporal c o n t e x t of the study w i l l be e x p l a i n e d . The Study Arr.-. l i e s w i t h i n the No r t h H e a l t h U n i t of the C i t y of Vancouver. The Study Area was choosen because i t encompasses Vancouver's s k i d - r o w . The bo u n d a r i e s were choosen because they are c o n t i g u o u s w i t h t h r e e census t r a c t s ( T r a c t s 57, 4 58 and 59) so t h a t T.B. r a t e s w i t h i n the Study Area c o u l d be c a l c u l a t e d . F i n a l l y the Study Area c o n t a i n s the DCHC's t a r g e t p o p u l a t i o n . A map of the N o r t h H e a l t h U n i t of the C i t y Vancouver i s e n c l o s e d showing the Study A r e a . W i t h i n the Study Area census t r a c t s 57 ( S t r a t h c o n a ) 58 (Downtown-Eastside) and 59 (Downtown-Core) are d e l i m i t e d . (Appendix A) Data were gathered f o r the y e a r s 1977-79 and 1981-83. No data were g a t h e r e d f o r 1980 because t h i s was the ' s t a r t - u p ' year f o r the DCHC. I t was f e l t t h a t the e v a l u a t i o n would be f a i r e r and more r e p r e s e n t a t i v e by e x c l u d i n g the c l i n i c ' s f i r s t year of o p e r a t i o n . Throughout t h i s t h e s i s , the term 'Study P e r i o d ' r e f e r s t o the s i x y e a r s f o r which data were g a t h e r e d . That i s , 1977-79 and 1981-83. 5 CHAPTER 2 . TUBERCULOSIS EPIDEMIOLOGY 2 . 1 TUBERCULOSIS PATHOGENESIS: Pulmonary t u b e r c u l o s i s i s caused by Mycobacterium t u b e r c u l o s i s which i s u s u a l l y t r a n s m i t t e d by a i r b o r n e d r o p l e t n u c l e i . I n f e c t i o u s persons produce d r o p l e t s , through coughing, c o n t a i n i n g the b a c t e r i u m . These dry and the r e s u l t i n g d r o p l e t n u c l e i can remain suspended i n a i r f o r l o n g p e r i o d s of time. The M.  t u b e r c u l o s i s i s k i l l e d by u l t r a - v i o l e t l i g h t i n c l u d i n g d a y l i g h t so the b a c t e r i u m s u r v i v e s best i n dark, p o o r l y v e n t i l a t e d environments. Often such c o n d i t i o n s are a s s o c i a t e d w i t h p o v e r t y and crowded l i v i n g c o n d i t i o n s and t h u s , not s u r p r i s i n g l y t u b e r c u l o s i s has been a s s o c i a t e d w i t h slums, p o v e r t y and d e p r i v a t i o n . P r i m a r y t u b e r u l o s i s i n f e c t i o n f o l l o w s the i n h a l a t i o n of t u b e r c l e b a c i l l i i n t o the pulmonary a i r spaces. The b a c t e r i a a r e i n g e s t e d by macrophages and t r a n s p o r t e d t o r e g i o n a l lymph nodes. Two t o ten weeks a f t e r p r i m a r y i n f e c t i o n the host d e v e l o p s c e l l u l a r h y p e r s e n s i t i v i t y t o M. t u b e r c u l o s i s a n t i g e n s . T h i s h y p e r s e n s i t i v i t y may be observed when t u b e r c u l o p r o t e i n i s i n j e c t e d i n t r a d e r m a l l y i n t o the host p r o d u c i n g a s k i n r e a c t i o n . The p r i m a r y t u b e r c u l o s i s l e s i o n s i n the l u n g and l o c a l lymph nodes u s u a l l y h e a l . However, these h e a l e d l e s i o n s may c o n t a i n v i a b l e M. t u b e r c u l o s i s organisms f o r many y e a r s . These l e s i o n s may p r o v i d e innoculum f o r spread t o o t h e r body s i t e s through the lymph and c i r c u l a t o r y systems and/or be the source f o r r e a c t i v a t i o n of the d i s e a s e . 6 When prim a r y t u b e r c u l o s i s i n f e c t i o n o c c u r s the l e s i o n s u s u a l l y h e a l and remain h e a l e d over the l i f e of the i n f e c t e d i n d i v i d u a l . I f however, the prim a r y innoculum i s l a r g e and/or i f the host i s unde r n o u r i s h e d or o t h e r w i s e l a c k s r e s i s t a n c e , the pri m a r y i n f e c t i o n may become r e a c t i v a t e d . C l i n i c a l t u b e r c u l o s i s i s u s u a l l y a r e a c t i v a t i o n of the pr i m a r y i n f e c t i o n which may f o l l o w w i t h i n weeks of pr i m a r y i n f e c t i o n but more o f t e n o c c u r s a f t e r a p e r i o d of y e a r s . The r i s k of p r i m a r y i n f e c t i o n i s determined e n t i r e l y by exposure which i s determined by e n v i r o n m e n t a l f a c t o r s . Thus, people who have household c o n t a c t w i t h a c t i v e t u b e r c u l o s i s c a s e s are at h i g h e s t r i s k f o r p r i m a r y i n f e c t i o n . However, the r i s k 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 depends on many f a c t o r s . Some of the known f a c t o r s i n f l u e n c i n g r e a c t i v a t i o n a re m a l n u t r i t i o n , r e n a l f a i l u r e , l a b i l e d i a b e t e s , s i l i c o s i s , 14 a d m i n i s t r a t i o n of immunosuppresive d r u g s . G e n e t i c p r e d i s p o s i t i o n t o r e a c t i v a t i o n d i s e a s e has been demonstrated i n t w i n s . Age i s a major f a c t o r w i t h i n f a n t s and young a d u l t s l e a s t r e s i s t a n t . D e p r i v e d socio-economic c o n d i t i o n s a re a l s o a s s o c i a t e d w i t h r e a c t i v a t i o n . 2.2 TUBERCULOSIS EPIDEMIOLOGY i n DEVELOPED NATIONS: T u b e r c u l o s i s e p i d e m i o l o g y v a r i e s i n d i f f e r e n t c o u n t r i e s . F i g u r e 1 i s a s i m p l e model o u t l i n i n g the g e n e r a l p r i n c i p l e s of t u b e r c u l o s i s e p i d e m i o l o g y . A p p r o x i m a t e l y h a l " the wo r l d s ' p o p u l a t i o n a re u n i n f e c t e d persons 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 r e c t i o n s . In developed c o u n t r i e s , the m a j o r i t y of persons of a l l ages a re u n i n f e c t e d . In d e v e l o p i n g c o u n t r i e s o f t e n the m a j o r i t y of a d u l t s 7 are i n f e c t e d so t h a t the u n i n f e c t e d group c o n s i s t s of c h i l d r e n who are "not yet i n f e c t e d . " FIGURE 1 A GENERAL MODEL OF T.B. EPIDEMIOLOGY. TUBERCULOSIS I N F E C T E D T u b e r c u l i n P o s i t i v e . N O T I N F E C T E D T u b e r c u l i n N e g a t i v e . Source: D a n i e l , T.M., " S e l e c t i v e Primary H e a l t h 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 the D e v e l o p i n g World, I I : T u b e r c u l o s i s . " Reviews of I n f e c t i o u s D i s e a s e s , 6:1254-1265, 1982, ( 1 4 ) . I n f e c t e d persons a r i s e from the u n i n f e c t e d group. As s t a t e d i n S e c t i o n 2.1 the r i s k f o r p r i m a r y i n f e c t i o n depends on exposure. Once exposure has o c c u r r e d r e a c t i v a t i o n r i s k depends on host f a c t o r s o f t e n l i n k e d w i t h p o v e r t y , m a l n u t r i t i o n and poor l i v i n g c o n d i t i o n s . A p o r t i o n i n the i n f e c t e d p o o l goes on t o d e v e l o p t u b e r c u l o s i s . In the U n i t e d S t a t e s , s t u d i e s i n d i c a t e t h a t a p p r o x i m a t e l y 5% of i n f e c t e d persons s u b s e q u e n t l y d e v e l o p 14 r e a c t i v a t i o n t u b e r c u l o s i s . In d e v e l o p i n g c o u n t r i e s where i n c i d e n c e r a t e s can be h i g h , the r i s k of exposure i s h i g h . R i s k of r e a c t i v a t i o n may a l s o be h i g h f o r the poor i n d e v e l o p i n g n a t i o n s . These f a c t o r s i n c o m b i n a t i o n w i t h p o o r l y o r g a n i z e d 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 f o r .the c o n t r o l and e r a d i c a t i o n of the d i s e a s e p a r t i c u l a r l y as a h i g h e r 8 percentage of t u b e r c u l o s i s c ases may be i n f e c t i o u s under c o n d i t i o n s where the d i s e a s e i s u n t r e a t e d , i n a d e q u a t e l y t r e a t e d or remains u n t r e a t e d u n t i l i t reaches an advanced s t a t e . In developed c o u n t r i e s the e p i d e m i o l o g y i s q u i t e d i f f e r e n t . "There i s r e l i a b l e e v i d e n c e t h a t i r r e s p e c t i v e of i t ' s magnitude, the t u b e r c u l o s i s problem i n developed c o u n t r i e s has been 39 d e c r e a s i n g from a t l e a s t the t u r n of t h i s c e n t u r y . " R e l i a b l e f i g u r e s from the N e t h e r l a n d s i n d i c a t e t h a t between the two w o r l d wars, m o r t a l i t y r a t e s and i n f e c t i o n r a t e s were d e c r e a s i n g at a r a t e of a p p r o x i m a t e l y 5% per y e a r . These d e c r e a s e s were l i k e l y due t o improvements i n socio-economic c o n d i t i o n s r a t h e r than 39 i n s t i t u t i o n of s p e c i f i c c o n t r o l measures. The downward t r e n d 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 the e r a of chemotherapy was about 5%. T h i s r a t e has i n c r e a s e d s i n c e the i n t r o d u c t i o n of chemotherapy so t h a t i n f e c t i o n r a t e s i n d eveloped 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 12-13% a n n u a l l y . I t i s l i k e l y t h a t the d i f f e r e n c e between the pre-chemotherapy and post-chemotherapy i n f e c t i o n r a t e s i s due t o enhanced c a s e - f i n d i n g 39 and chemotherapy i n these c o u n t r i e s . High l i v i n g s t a n d a r d s , good c a s e - f i n d i n g and treatment have reduced the r i s k of exogenous i n f e c t i o n i n developed c o u n t r i e s so the main c o n t r i b u t i o n t o t u b e r c u l o s i s i n developed c o u n t r i e s a r i s e s through endogenous e x a c e r b a t i o n of the d i s e a s e i n c o h o r t s which a r e a l r e a d y i n f e c t e d . In Canada, these c o h o r t s c o n s i s t m a i n l y of o l d e r p e o p l e , immigrants and a b o r i g i n a l p e o p l e . 9 2 .3 THE COHORT EFFECT: One of the most i n t r i g u i n g f a c e t s of t u b e r c u l o s i s epidemiology ( p a r t i c u l a r l y i n developed c o u n t r i e s ) i s the 'cohort e f f e c t ' . People i n developed c o u n t r i e s born i n those c o u n t r i e s i n an e r a of h i g h e r T.B. r a t e s were a t g r e a t e r r i s k of exposure to the ba c t e r i u m and subsequent p r i m a r y i n f e c t i o n . T h i s was shown i n a Saskatchewan study u s i n g mass t u b e r c u l i n t e s t i n g s t a r t i n g i n 1955 t o de v e l o p a t u b e r c u l i n r e g i s t r y of p o s i t i v e r e a c t o r s i n 4 the p r o v i n c e . In the mid-60's t h i s r e g i s t r y showed p o s i t i v e r e a c t i o n s i n c r e a s e d w i t h i n c r e a s i n g age. For ages 0-14, 1% showed p o s i t i v e r e a c t i o n s . For ages 15-19, 4.4% were p o s i t i v e and f o r ages 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 steady r e a c h i n g a maximum of 55% f o r those aged 60 and o v e r . C l e a r l y , the 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 age of the c o h o r t . From the model i n F i g u r e 1 i t i s a l s o c l e a r t h a t the l a r g e r the p o o l of i n f e c t e d people the g r e a t e r the p r o b a b l i l i t y f o r r e a c t i v a t i o n s t o o c c u r . I t i s t h e r e f o r e no s u r p r i s e t h a t i n developed c o u n t r i e s (where the r o l e of exogenous r e - i n f e c t i o n has been reduced) t u b e r c u l o s i s i s p r i m a r i l y seen as r e a c t i v a t i o n d i s e a s e i n o l d e r segments of the p o p u l a t i o n born i n t h a t c o u n t r y . The r i s k of 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 i s a r e s u l t of h i g h exposure t o p r i m a r y i n f e c t i o n i n .youth. When immigrants from c o u n t r i e s w i t h h i g h T.B. r a t e s move t o developed c o u n t r i e s w i t h low r a t e s a s i m i l a r phenomenon i s observed. I f these immigrants had h i g h exposure t o primary i n f e c t i o n i n t h e i r y outh even a f t e r they move t o a c o u n t r y w i t h low r a t e s they tend 10 to e x h i b i t h i g h r a t e s of endogenous r e a c t i v a t i o n . T h i s was shown r a t h e r e l e g a n t l y i n a study by Enarson, S j o g r e n , 19 and Grzybowski of F i n n i s h immigrants t o Canada. They c a l c u l a t e d the 1970-72 i n c i d e n c e r a t e s of F i n n i s h immigrants l i v i n g i n Canada and compared them w i t h 1970-72 r a t e s i n F i n l a n d . ( F i n l a n d has h i s t o r i c a l l y had h i g h e r r a t e s than Canada. In 1970-72 T.B. r a t e s i n F i n l a n d were about 7 times Canadian r a t e s . ) The study showed t h a t F i n n i s h immigrants who had l i v e d i n Canada an average of 40 y e a r s had r a t e s s i m i l a r t o those i n F i n l a n d . The a u t h o r s of t h i s study concluded t h a t h i g h e r r a t e s among F i n n i s h immigrants t o Canada compared t o the Canadian-born p o p u l a t i o n were due t o i n c r e a s e d exposure d u r i n g t h e i r youth i n F i n l a n d and subsequent endogenous r e a c t i v a t i o n a t a h i g h e r r a t e i n Canada than the Canadian-born p o p u l a t i o n . (The c o h o r t e f f e c t was superimposed on t h i s , as r a t e s among the F i n n i s h immigrants i n c r e a s e d s t e a d i l y w i t h age of the c o h o r t . ) In Canada, 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 ther major h i g h -r i s k group. Because m o r t a l i t y and i n c i d e n c e r a t e s were much h i g h e r f o r a b o r i g i n a l people than the n o n - a b o r i g i n a l Canadian-born p o p u l a t i o n , t h e r e i s a p r o p o r t i o n a t e l y l a r g e r i n f e c t e d group i n the a b o r i g i n a l p o p u l a t i o n compared to the n o n - a b o r i g i n a l p o p u l a t i o n . A l s o , because r a t e s f o r the a b o r i g i n a l p o p u l a t i o n were h i g h so r e c e n t l y , the l e v e l of pri m a r y i n f e c t i o n i s h i g h i n younger age c o h o r t s . Thus, t u b e r c u l o s i s among Canadian a b o r i g i n e s tends t o occur i n younger age-groups than f o r the n o n - a b o r i g L n s l Canadian-born p o p u l a t i o n . In Canada, o l d e r members of the Canadian-born p o p u l a t i o n , a b o r i g i n a l p e o p l e s and immigrants from c o u n t r i e s w i t h h i g h T.B. 1 1 r a t e s a re some of the major s o c i o - d e m o g r a p h i c a l l y i d e n t i f i a b l e h i g h - r i s k groups f o r t u b e r c u l o s i s . Endogenous r e a c t i v a t i o n i s l i k e l y the major mechanism of t u b e r c u l o s i s p r e s e n t a t i o n i n these groups. T h e r e f o r e any f a c t o r s which i n c r e a s e host s u s c e p t i b i l i t y f o r r e a c t i v a t i o n ( l i k e p o v e r t y ) w i l l l i k e l y i n c r e a s e the number of cases w i t h i n these h i g h - r i s k groups. 1 2 CHAPTER 3. THE EVOLUTION OF TUBERCULOSIS TREATMENT 3.1 INTRODUCTION: The purpose of t h i s c h a p t e r i s to p l a c e the DCHC and WCC i n broad h i s t o r i c a l c o n t e x t . That i s , t o d e s c r i b e the developments i n t u b e r c u l o s i s treatment which have l e d to o u t - p a t i e n t s e r v i c e s based a t h o s p i t a l s ( l i k e the WCC) or i n l o c a l communities. ( l i k e the DCHC) 3.2 THE PRE-MODERN ERA AND TUBERCULOSIS TREATMENT: T u b e r c u l o s i s i s a d i s e a s e of grea t a n t i q u i t y . A c c o r d i n g t o Moorman, " The s e r i o u s study of h i s t o r y j u s t i f i e s the b e l i e f t h a t T.B. may have been the f i r s t born of the mother of 30 p e s t i l e n c e and d i s e a s e . " T u b e r c u l o s i s was t h e r e f o r e w e l l known t o pre-modern p e o p l e s . P h y s i c i a n s i n d i f f e r e n t c u l t u r e s of the a n c i e n t w o r l d used w i d e l y v a r y i n g t r e a t m e n t s t o cu r e the d i s e a s e . The Indo-Aryans used a h y g i e n i c - d i e t e t i c treatment t o improve the g e n e r a l c o n d i t i o n of p a t i e n t s . The Romans p r a c t i c e d c l i m o t h e r a p e u t i c t r e a t m e n t s so t h a t " i n I m p e r i a l Rome i t became the custom t o send people a f f l i c t e d w i t h pulmonary m a l a d i e s t o S i c i l y and Egypt as 16 i t was w e l l known they would o f t e n r e t u r n c u r e d . " A v a r y i n g m i x t u r e of d i e t e t i c , c l i m a t i c and o c c u l t cures were advocated by the p h y s i c i a n s of a n t i q u i t y and Europe i n the M i d d l e Ages. D u r i n g the Renaissance i n Europe, the concept t h a t t u b e r c u l o s i s might be c o n t a g i o u s began t o g a i n credence. In 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 c l e a r l y e x p r e s s e d a t h e o r y on the i n f e c t i v i t y and c o n t a g i o u s n e s s of 13 t u b e r c u l o s i s i n h i s book De M o r b i s C o n t a g i o s i s . T h i s t h e o r y was g e n e r a l l y a c c e p t e d i n Southern Europe and a t t a i n e d widespread b e l i e f so t h a t i n p a r t s of I t a l y and Spain laws were promulgated making t u b e r c u l o s i s a r e p o r t a b l e d i s e a s e and encouraging d i s i n f e c t a n t p rocedures f o r h a n d l i n g t u b e r c u l o s i s c o r p s e s and l i v e p a t i e n t s . These p u b l i c h e a l t h laws were r i g o r o u s l y e n f o r c e d 16 i n Spain and I t a l y . However, N o r t h e r n European p h y s i c i a n s tended t o r e g a r d t u b e r c u l o s i s as a h e d i t a r y - f a m i l i a l d i s e a s e and scorned the c o n t a g i o n t h e o r y . These p h y s i c i a n s b e l i e v e d t h a t " r e s t , balmy a i r and sunny s k i e s c o u l d a r r e s t the d e s t r u c t i o n of l u n g t i s s u e and the s a p ping of s t r e n g t h t h a t o t h e r w i s e drove the consumptive t o 1 6 c e r t a i n death i n the space of a few y e a r s . " The i d e n t i f i c a t i o n of the t u b e r c u l e b a c i l l i i n 1882 by Robert Koch, demolished the 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 o r i g i n . Once people r e a l i z e d t u b e r c u l o s i s was caused by a germ, san a t o r i u m based treatment methods began t o d e v e l o p . In f a c t , s a natorium based treatment dominated the f i r s t p e r i o d of the modern era of t u b e r c u l o s i s t r e a t m e n t . 3.3 THE MODERN ERA OF TUBERCULOSIS TREATMENT: The modern era i n t u b e r c u l o s i s treatment can be d i v i d e d i n t o two p e r i o d s . The f i r s t p e r i o d l a s t e d from 1882 u n t i l 1945 and saw the development of s u r g i c a l t e c h n i q u e s and the widespread b u i l d i n g of s a n a t o r i a t o t r e a t t u b e r c u l o s i s . The second p e r i o d s t a r t e d a f t e r World War I I w i t h the d i s c o v e r y of s t r e p t o m y c i n and the subsequent development of t u b e r c u l o s i s chemotherapy. 1 . S u r g i c a l treatment of t u b e r c u l o s i s . In 1882, F o r l a n i n i f i r s t induced a r t i f i c i a l pneumothorax or 1 4 49 the s u r g i c a l c o l l a p s e of the l u n g . I t took 30 y e a r s f o r t h i s s u r g i c a l method t o g a i n the 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 r a t i o n a l e behind s u r g i c a l c o l l a p s e of the l u n g was t h a t i t a l l o w e d time f o r the t u b e r c u l a r l e s i o n s t o h e a l . As s a n a t o r i a expanded i n the e a r l y t w e n t i e t h c e n t u r y , so d i d the frequency of pneumothorax s u r g e r y . A m i x t u r e of s a n a t o r i u m treatment and s u r g e r y was the normal treatment f o r t u b e r c u l o s i s f o r the f i r s t h a l f of the t w e n t i e t h c e n t u r y u n t i l the widespread use of a n t i b i o t i c s i n the mid-1950's. 2 . S a n a t o r i a . The f i r s t s a n a t o r i u m f o r t u b e r c u l o s i s treatment was s t a r t e d by 1 4 Hermann Brehmer i n Germany i n 1854. The d e m o n s t r a t i o n by Koch of t u b e r c u l o s i s i n f e c t i v i t y l e n t enormous impetus t o the s a n a t o r i u m b u i l d i n g movement. The m o t i v a t i o n f o r b u i l d i n g s a n a t o r i a was two pronged a f t e r Koch's d i s c o v e r y . F i r s t l y , s a n a t o r i a c o u l d h e l p cure or a r r e s t the d i s e a s e and s e c o n d l y they h e l p e d i s o l a t e i n f e c t i v e people from h e a l t h y p e o p l e . In N o r t h America, s a n a t o r i a were modelled on Dr. Trudeau's 1 4 s a n a t o r i u m a t Saranac Lake, New York which he b u i l t i n 1884. The f i r s t Canadian 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 i n 1896. In Canada s e v e r a l phases of s a n a t o r i a development are apparent. The f i r s t stage saw the 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 , i s o l a t e d , o f t e n d r y and mountainous a r e a s . The T r a n q u i l l e s anatorium near Kamloops i n B r i t i s h Columbia was b u i l t d u r i n g t h i s e r a (1908). As the Canadian p o p u l a t i o n u r b a n i z e d and as t u b e r c u l o s i s e p i d e m i o l o g y s h i f t e d from a r u r a l t o an urban f o c u s the second 15 stage of sanatorium development u n f o l d e d i n Canada. In t h i s s t a g e , s a n a t o r i a were b u i l t n earer c e n t r e s of p o p u l a t i o n and i n l a r g e r urban c e n t r e s began i n t e g r a t i o n w i t h g e n e r a l h o s p i t a l s . T u b e r c u l o s i s treatment by t h i s stage was b e g i n n i n g i t ' s r e -i n t e g r a t i o n w i t h mainstream medicine a f t e r n e a r l y a c e n t u r y of r e l a t i v e i s o l a t i o n i n remote s a n a t o r i u m s . V o l u n t a r y s o c i e t i e s p l a y e d a major r o l e i n s e t t i n g up and fun d i n g s a n a t o r i a i n the f i r s t twenty y e a r s of the c e n t u r y i n Canada. As the c o s t s and c o m p l e x i t i e s of run n i n g t u b e r c u l o s i s s a n a t o r i a i n c r e a s e d , p r o v i n c e s began t o take over t h e i r management r e l e g a t i n g v o l u n t a r y s o c i e t y a c t i v i t i e s t o fund r a i s i n g and t u b e r c u l o s i s e d u c a t i o n . By the 1930's, h a l f of Canada's p r o v i n c e s ( i n c l u d i n g B.C.) had e s t a b l i s h e d d i r e c t 7 p r o v i n i c i a l government c o n t r o l over t u b e r c u l o s i s t r e a t m e n t . The 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 h a l f of the t w e n t i e t h c e n t u r y was accompanied by the almost m e s s i a n i c e d u c a t i o n a l and o r g a n i z a t i o n a l z e a l of the 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 s o c i e t i e s r a i s e d money f o r t u b e r c u l o s i s e d u c a t i o n and f a c i l i t i e s . T h i s e r a a l s o saw the development of mass X-ray programs and the d i s c o v e r y of the BCG v a c c i n e which l e d t o more e f f i c i e n t case f i n d i n g and p r e v e n t i o n measures. The i n t e r a c t i o n of i n c r e a s e d case f i n d i n g , i n c r e a s e d i s o l a t i o n and treatment i n 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 the g e n e r a l p o p u l a t i o n c o i n c i d e d w i t h a decrease i n t u b e r c u l o s i s death r a t e s and p r e v a l e n c e . However, i t wasn't u n t i l a f t e r the 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 d e c l i n e . 1 6 3.Chemotherapy. The second e r a i n modern T.B. treatment began w i t h the d i s c o v e r y of s t r e p t o m y c i n i n 1944. By 1945, the f i r s t human t r e a t m e n t s were c a r r i e d out a t the Mayo C l i n i c and by 1947 the 49 drug 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 chemotherapy. The d i s c o v e r y of 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 ( i n 1946) by t h a t of p a r a - a m i n o s a l i c y l i c a c i d (PAS) and i s o n i a z i d (INH) i n 49 1952. These t h r e e drugs became the p h a r m a c o l o g i c a l armamentarium of the 1950's and 60's i n the world-wide d r i v e t o cur e t u b e r c u l o s i s . S t r e p t o m y c i n had d i s a d v a n t a g e s because i t i s t o x i c t o the e i g h t h c r a n i a l nerve and i n some p a t i e n t s caused l o s s of b a l a n c e and d e afness and because i t had t o be a d m i n i s t e r e d by i n t r a m u s c u l a r i n j e c t i o n on a d a i l y b a s i s . A l s o , b a c t e r i a l r e s i s t a n c e t o the drug became common when the drug was g i v e n a l o n e . Combination regimes u s i n g s t r e p t o m y c i n , PAS, and INH were developed to reduce occurence of b a c t e r i a l r e s i s t a n c e . In Canada and most o t h e r c o u n t r i e s , s t a n d a r d t u b e r c u l o s i s chemotherapy i n the 50's and 60's c o n s i s t e d of a d a i l y regime w i t h a c o m b i n a t i o n of these drugs l a s t i n g f o r 18 t o 24 months. In the 40's and 50's therapy was mai n l y c a r r i e d out w i t h i n the s a n a t o r i a . By the 1960's drugs were i n c r e a s i n g l y g i v e n on an o u t - p a t i e n t b a s i s . A l t h o u g h s t r e p t o m y c i n was b e g i n n i n g t o become a v a i l a b l e f o r m e d i c a l use j u s t a f t e r World War 2 i t took n e a r l y a decade t o a t t a i n g e n e r a l i z e d use i n Canadian s a n a t o r i a . In 1947 0.01% of san a t o r i u m p a t i e n t s were r e c e i v i n g s t e p t o m y c i n . By 1954 t h i s 1 7 percentage had i n c r e a s e d t o 81%. By 1954 74% of p a t i e n t s were a l s o r e c e i v i n g PAS. By 1956 50% of s a n a t o r i u m p a t i e n t s were 36 r e c e i v i n g INH. T h i s went up t o 84% by 1959. Canadian and B.C. death r a t e s f o r t u b e r c u l o s i s responded a c c o r d i n g l y . (Table 1) TABLE I : T u b e r c u l o s i s Death Rates i n Canada and B.C.(per 100,000) YEAR CANADA B.C. 1945 47.2 55.3 1952 17.6 17.8 1 962 4.2 2.9 1972 2.1 1 .8 1982 0.6 0.5 Problems of b a c t e r i a l r e s i s t a n c e and drug t o x i c i t y became apparent t o c l i n i c i a n s a f t e r a few y e a r s e x p e r i e n c e w i t h t u b e r c u l o s i s chemotherpy. These problems gave impetus f o r r e s e a r c h i n t o l e s s - t o x i c 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 i n 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 drug r e s i s t a n c e . In the 1960's, two drugs were found (ethambutol and r i f a m p i c i n ) which met some of these p r o p e r t i e s . A f t e r development of these drugs d a i l y c o m b i n a t i o n 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 chemotherapy and i t ' s subsequent e f f e c t on t u b e r c u l o s i s death 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 the e s t a b l i s h e d t u b e r c u l o s i s t r e atment system. S a n a t o r i a had been expanding p r i o r t o chemotherapy f o r t u b e r c u l o s i s . For example, i n 1947 t h e r e were 3.32 m i l l i o n p a t i e n t days spent i n Canadian p r o v i n c i a l l y run s a n a t o r i a . T h i s f i g u r e peaked at 6.22 m i l l i o n p a t i e n t - d a y s i n 1953 and d e c l i n e d t o 2.43 m i l l i o n by 1961, a 37 drop of more than 60%. 18 A l t h o u g h i t was cheaper t o t r e a t p a t i e n t s i n s a n a t o r i a than g e n e r a l h o s p i t a l s , as the occupancy dropped i n s a n a t o r i a i n response t o lowered t u b e r c u l o s i s r a t e s so d i d t h e i r f i s c a l e f f i c i e n c y i n r e l a t i o n t o g e n e r a l h o s p i t a l s . Another f a c t o r i n s a n a t o r i a d e c l i n e was s h o r t e n e d l e n g t h of s t a y i n i n s t i t u t i o n s because of the new chemotherapy. For example, i n 1954 the average l e n g t h of s t a y f o r Canadian t u b e r c u l o s i s f i r s t a d m i s s i o n s and r e a d m i s s i o n s was 394 days. By 1961, t h i s had been h a l v e d to 199 37 days. C l e a r l y , by the mid-50's the impact of chemotherapy and r i s i n g s t a n d a r d s of l i v i n g were making themselves f e l t i n Canadian s a n a t o r i a . R e d u c t i o n i n the number of p a t i e n t days and d e creases i n l e n g t h of s t a y reduced occupancy. A l s o , new drugs rendered p a t i e n t s n o n - i n f e c t i v e r a p i d l y so sanatorium-based advantages of p a t i e n t i s o l a t i o n were no l o n g e r a major c o n c e r n . These f a c t o r s speeded the r e i n t e g r a t i o n of t u b e r c u l o s i s t r e atment s e r v i c e s w i t h mainstream m e d i c a l t r e a t m e n t s e r v i c e s o f f e r e d i n g e n e r a l h o s p i t a l s . T h i s r e i n t e g r a t i o n p r o c e s s was hastened by the p a s s i n g of the Canadian H o s p i t a l Insurance Act of 1957. T h i s a c t e s s e n t i a l l y o f f e r e d 50% c o s t s h a r i n g f o r g e n e r a l h o s p i t a l s e r v i c e s . I t was i n the p r o v i n c e s ' best f i n a n c i a l i n t e r e s t s t o i n t e g r a t e t u b e r c u l o s i s s e r v i c e s i n t o a g e n e r a l h o s p i t a l i n o r d e r t o r e c e i v e f i n a n c i a l s upport from the f e d e r a l government under t h i s a c t . T h i s changing r e a l i t y was o f f i c i a l l y recogr.i,:ed by the Royal Commission on H e a l t h S e r v i c e s c h a i r e d by Mr. J u s t i c e Emmett H a l l i n the Commission's 1965 p u b l i c a t i o n ' T u b e r c u l o s i s i n Canada'. In i t ' s c o n c l u s i o n s the a u t h o r s recommended t h a t t u b e r c u l o s i s 19 s e r v i c e s " s h o u l d be i n t e g r a t e d i n t o community and g e n e r a l m e d i c a l s e r v i c e s where p o s s i b l e " and t h a t " t u b e r c u l o s i s s h o u l d be i n c l u d e d 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 F e d e r a l Government p a r t i c i p a t i o n t o the same e x t e n t as f o r other 7 d i s e a s e s . " These g e n e r a l e p i d e m i o l o g i c a l and treatment t r e n d s were o c c u r i n g throughout the i n d u s t r i a l i z e d 'developed' w o r l d . However, most of the i n n o v a t i v e r e s e a r c h on t u b e r c u l o s i s chemotherapy had s h i f t e d t o d e v e l o p i n g c o u n t r i e s . The c o m b i n a t i o n of chemotherapy and i n c r e a s e d post-war s t a n d a r d s of l i v i n g i n the developed c o u n t r i e s r a p i d l y r e l e g a t e d t u b e r c u l o s i s t o a d i s e a s e of poor, m a r g i n a l , u s u a l l y urban p e o p l e . In 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 c a s e - f i n d i n g and treatment had numerous problems because of more g e n e r a l i z e d p o v e r t y and the r e l a t i v e underdevelopment of h e a l t h s e r v i c e s . M e d i c a l i n t e r e s t i n t u b e r c u l o s i s i n developed c o u n t r i e s waned as h e a r t d i s e a s e and cancer death r a t e s i n c r e a s e d r e l a t i v e to those 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 apparent to the R o y a l Commission on H e a l t h S e r v i c e s i n 1965. In t h i s r e p o r t the a u t h o r s s t a t e d : " There i s d i f f i c u l t y i n m a i n t a i n i n g competent m e d i c a l s t a f f f o r t u b e r c u l o s i s s e r v i c e s . T u b e r c u l o s i s does not 7 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 p e r s o n n e l . " Thus, by the 1950's and 60's the d e v e l o p i n g c o u n t r i e s became the p r o v i n g ground f o r t u b e r c u l o s i s chemotherapy. The t h r e e major l o c i of t u b e r c u l o s i s r e s e a r c h i n the 50's and 60's were I n d i a , Kenya and Hong Kong. A 1959 study a t the Madras T u b e r c u l o s i s Chemotherapy Centre compared outcome from s t a n d a r d t u b e r c u l o s i s 20 chemotherapy a d m i n i s t e r e d i n a h o s p i t a l and s e l f -45 a d m i n i s t e r e d at home. The study c l e a r l y showed t h a t even w i t h the impoverished home c o n d i t i o n s of many of the Madras p a t i e n t s , h o s p i t a l i z a t i o n was not nec e s s a r y t o t r e a t pulmonary t u b e r c u l o s i s . T h i s study e s t a b l i s h e d t h a t o u t - p a t i e n t based t u b e r c u l o s i s chemotherapy was not o n l y p o s s i b l e but advantageous from a treatment outcome and c o s t p o i n t of view. The Madras study r e s u l t s 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 o u t - p a t i e n t compliance t o tr e a t m e n t . Subsequent r e s e a r c h e f f o r t s a t the Madras Centre d u r i n g the 1960's focused on development of s u p e r v i s e d i n t e r m i t t e n t as opposed t o u n s u p e r v i s e d d a i l y chemotherapy regimes i n an e f f o r t t o make p a t i e n t s comply more 46,47 f u l l y . R e s u l t s of these Madras s t u d i e s e s t a b l i s h e d the t h e r a p e u t i c e q u a l i t y of s u p e r v i s e d i n t e r m i t t e n t treatment w i t h u n s u p e r v i s e d d a i l y o u t - p a t i e n t t r e a t m e n t . S i m i l a r r e s u l t s were o b t a i n e d i n c o n t r o l l e d s t u d i e s a t o t h e r r e s e a r c h c e n t r e s i n the 15,50 60's and 70's. In the 1970's the r e s e a r c h focus s h i f t e d t o s h o r t e n i n g the t r a d i t i o n a l l e n g t h of chemotherapy. The d i s c o v e r y of r i f a m p i c i n i n 1968 and i t ' s e f f i c a c y a g a i n s t t u b e r c u l o s i s r a i s e d the p o s s i b i l i t y of s h o r t e n i n g the t r a d i t i o n a l l e n g t h of t u b e r c u l o s i s chemotherapy. 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 of the B r i t i s h M e d i c a l Research C o u n c i l i n Kenya, Tanzania (then Tanganyka) and Hong Kong t e s t e d v a r i o u s c o m b i n a t i o n s of a n t i - t u b e r c u l a r 18,27 drugs f o r p e r i o d s of 6 and 9 months. By the mid-70's, r e s e a r c h c l e a r l y showed t h a t i n t e r m i t t e n t s u p e r v i s e d o u t - p a t i e n t chemotherapy f o r p e r i o d s as s h o r t as 6 months were e f f e c t i v e i n 21 t r e a t i n g t u b e r c u l o s i s i n d e v e l o p i n g c o u n t r i e s . The e v o l u t i o n of shortened i n t e r m i t t e n t o u t - p a t i e n t based treatment 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 importance of p a t i e n t c o m p l i a n c e . These treatment methods are o n l y e f f e c t i v e i f p a t i e n t s took the m e d i c a t i o n . T h i s r e a l i z a t i o n r e s u l t e d i n a number of s t u d i e s on compliance t o t u b e r c u l o s i s o u t - p a t i e n t t herapy (See Chapter 6) and emphasis on d e s i g n i n g treatment systems t h a t promote compliance. Even though hard data based on r e l a t i v e l y d i f f i c u l t - t o - t r e a t p o p u l a t i o n s i n d e v e l o p i n g c o u n t r i e s showed t h a t changes i n t r a d i t i o n a l t u b e r c u l o s i s chemotherapy were i n o r d e r , developed c o u n t r i e s were slow to adapt the new f i n d i n g s t o t h e i r own treatment systems. Thus C z e c h o s l o v a k i a was one of the f i r s t i n d u s t r i a l i z e d c o u n t r i e s to o f f i c i a l l y adopt i n t e r m i t t e n t 32 t u b e r c u l o s i s chemotherapy i n 1972. In 1976 the B r i t i s h T h o r a c i c A s s o c i a t i o n recommended the use of s h o r t - c o u r s e i n t e r m i t t e n t 1 3 chemotherapy i n B r i t a i n . The f i r s t t r i a l of i n t e r m i t t e n t s u p e r v i s e d chemotherapy i n N orth America o c c u r r e d i n 1967 on 25 m a i n l y a l c o h o l i c ' r a c a l c i t r a n t ' t u b e r c u l o s i s p a t i e n t s i n Denver, C o l o r a d o . T h i s s m a l l t r i a l , u s i n g t w i c e weekly INH and s t r e p t o m y c i n , showed no r e l a p s e s and no treatment f a i l u r e s a f t e r median treatment l e n g t h 34 of 12 months. In 1976 a l a r g e r s c a l e study was undertaken i n Arkansas t o t e s t the e f f i c a c y of tw"ce weekly s e l f - a d m i n i s t e r e d INH- r i f a m p i c i n treatment over a 9 month p e r i o d . The c o n c l u s i o n s of t h i s study were t h a t such treatment was s a f e , e f f e c t i v e and 1 7 e c o n o m i c a l . 22 A l t h o u g h some t r i a l s have been conducted i n N o r t h America and Europe, Fox c l a i m s t h a t d e v e l o p i n g n a t i o n s are u s i n g new advanced methods of chemotherapy whereas t e c h n i c a l l y advanced c o u n t r i e s are not. One reason he o f f e r s f o r t h i s unusual s i t u a t i o n i s t h a t the t e c h n i c a l l y advanced c o u n t r i e s pay l i t t l e a t t e n t i o n t o WHO p u b l i c a t i o n s and recommendations (which have 24 been the forum f o r most developments i n T.B. c o n t r o l ) . Another p o s s i b l e reason i s t h a t w i t h the d i s e a s e c o n f i n e d t o r e l a t i v e l y p o w e r l e s s o f t e n m a r g i n a l s u b - p o p u l a t i o n s i n developed c o u n t r i e s , the r e s o u r c e s are s i m p l y not b e i n g made a v a i l a b l e t o f i n a l l y e r a d i c a t e the d i s e a s e . (In t h i s l i g h t i t i s i n t e r e s t i n g t o note t h a t a l t h o u g h t u b e r c u l o s i s has been a problem i n Vancouver's Downtown area f o r y e a r s , i t r e c e i v e d widespread p r e s s a t t e n t i o n i n 1985 m a i n l y because M i n i s t r y of Human Resources workers were g e t t i n g the d i s e a s e . That i s , , t u b e r c u l o s i s i s news when middle c l a s s people get the d i s e a s e . ) In summary, 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 which u n t i l the advent of the a n t i - b i o t i c e r a was one of the l e a d i n g causes of death i n Europe and N o r t h - A m e r i c a . W i t h i n a decade a f t e r t h e i r i n t r o d u c t i o n , the c o m b i n a t i o n of r i s i n g l i v i n g s t a n d a r d s , i n c r e a s e d w e l l - b e i n g of the g e n e r a l p o p u l a t i o n and a n t i - b i o t i c s had r e v o l u t i o n i z e d t u b e r c u l o s i s e p i d e m i o l o l o g y and brought the d i s e a s e under c o n t r o l i n most developed c o u n t r i e s . However, the d i s e a s e remained r e l a t i v e l y i n t r a c t a b l e i n the c r u s h i n g p o v e r t y of most d e v e l o p i n g c o u n t r i e s . Research e f f o r t s s h i f t e d t o the d e v e l o p i n g n a t i o n s and by the l a t e 1960's o u t - p a t i e n t based chemotherapeutic treatment systems had been t e s t e d and the concept of i n t e r m i t t e n t chemotherapy f o r 23 t u b e r c u l o s i s had been e s t a b l i s h e d . The development of new drugs i n the l a t e 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 regimes by the mid 1970's. North-America was r e l a t i v e l y slow i n i n t r o d u c i n g these i n n o v a t i o n s . S l o w l y as s a n a t o r i a c l o s e d and t u b e r c u l o s i s treatment came under g e n e r a l h o s p i t a l c o n t r o l , t r e atment became more o u t - p a t i e n t based. The next c h a p t e r t r a c e s t h i s e v o l u t i o n i n 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 of the WCC and DCHC. 24 CHAPTER 4. TUBERCULOSIS CONTROL IN B . C . 4 .1 EARLY YEARS: E f f o r t s t o c o n t r o l t u b e r c u l o s i s i n B r i t i s h Columbia began at the t u r n of the c e n t u r y . In 1904 the B.C. S o c i e t y f o r the P r e v e n t i o n and Treatment of Consumption and Other Forms of T.B. was formed. In 1907 the B.C. A n t i - T . B . S o c i e t y was formed by a c t of l e g i s l a t u r e . Fund r a i s i n g was begun and a s a n a t o r i u m b u i l t a t T r a n q u i l l e near Ramloops. R e t u r n i n g v e t e r a n s from World War 1 s w e l l e d the numbers of T.B. cases needing treatment i n the p r o v i n c e , s t r a i n i n g the v o l u n t a r y s o c i e t y ' s f i n a n c i a l r e s o u r c e s . A c c o r d i n g l y , i n 1919 the B.C. government took over o p e r a t i o n of T r a n q u i l l e s a n a t o r i u m . A l t h o u g h the T r a n q u i l l e s a n a t o r i u m was the f o c a l p o i n t of the p r o v i n c e ' s a n t i - t u b e r c u l o s i s campaign, c l i n i c development was b e g i n n i n g i n Vancouver. In 1918 the R o t a r y I n s t i t u t e f o r D i s e a s e s of the Chest was s e t up i n Vancouver t o t r e a t T.B. p a t i e n t s a l o n g w i t h Vancouver G e n e r a l H o s p i t a l . However, t h e i r r o l e was minor compared t o t h a t of T r a n q u i l l e . By the e a r l y 1930's t u b e r c u l o s i s c o n t r o l and treatment was i n 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 i n the dry i n t e r i o r of the p r o v i n c e . E d u c a t i o n had been l e f t l a r g e l y t o the v o l u n t a r y s o c i e t i e s a l s o c e n t e r e d at T r a n q u i l l e . 4 .2 THE DIVISION OF T . B . CONTROL 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 was e s t a b l i s h e d i n 1935 and h e a d q u a r t e r e d at the Willow. S t r e e t Chest Centre i n Vancouver. The D i v i s i o n was s e t up by the p r o v i n c i a l Department of H e a l t h 25 and r e c e i v e d most of i t ' s f u n d i n g from the p r o v i n c i a l government. In 1936, the T r a n q u i l l e T.B. S o c i e t y was r e o r g a n i z e d and moved from T r a n q u i l l e t o Vancouver to a s s i s t the new d i v i s i o n i n terms of fund r a i s i n g and p u b l i c e d u c a t i o n . T u b e r c u l o s i s c o n t r o l , treatment and i n s t i t u t i o n s i n B.C. were b e g i n n i n g the t r e k away from r u r a l i s o l a t i o n towards an urban g e n e r a l h o s p i t a l s e t t i n g . In 1949 the B.C. T u b e r c u l o s i s I n s t i t u t e was opened as p a r t of the WCC. T h i s was f o l l o w e d s h o r t l y by the opening of a new s a n a t o r i u m i n 1952 (Pearson H o s p i t a l ) i n Vancouver. At t h i s p o i n t , i n B.C. and n a t i o n a l l y , s a n a t o r i u m bed c a p a c i t y was at i t ' s peak. I t i s somewhat i r o n i c t h a t the e f f e c t s of new a n t i -b i o t i c t h e r a p y began t o r e v e r b e r a t e through the treatment system so t h a t i n the B.C. D i v i s i o n of T.B. C o n t r o l Report f o r 1953 a s u r p r i s e d sounding d i r e c t o r s t a t e d : " D u r i n g the r e c e n t months an unusual s i t u a t i o n has been p e r c e i v e d at the D i v i s i o n of T.B. C o n t r o l i n t h a t t h e r e have been empty beds and a l l c a s e s except 40 f o r e l e c t i v e s u r g i - c a l c a s e s c o u l d be a d m i t t e d i m m e d i a t e l y . " The drop i n sanatorium p o p p u l a t i o n i n B.C. was d r a m a t i c as shown i n T a b l e I I . TABLE I I . S a n a t o r i a P o p u l a t i o n i n B.C. 1952-1964. YEAR TOTAL POPULATION i n B.C. SANATORIA. 1 952 838 1 955 615 1958 332 1 961 244 1 963 205 1964 163 Source: 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 B r i t i s h Columbia.Annual R e p o r t , 1965. Over the 14 year p e r i o d between 1952 and 1964 (which r o u g h l y c o r r e s p o n d s t o the e r a of complete i n t r o d u c t i o n of chemotherapy 26 f o r T.B.) the B.C. s a n a t o r i a p o p u l a t i o n dropped by over 500%. By 1958 T r a n q u i l l e Sanatorium was c l o s e d and t u b e r c u l o s i s beds became c e n t r a l i z e d i n the Vancouver area at the W i l l o w Chest C e n t r e , Pearson H o s p i t a l and the E ssondale Mental H e a l t h F a c i l i t y . As the s a n a t o r i a emptied, c a s e - f i n d i n g became the focus of the D i v i s o n of T.B. C o n t r o l . In 1957, a p r o v i n c i a l X-Ray and e x a m i n a t i o n program was s t a r t e d . T h i s was completed i n 1965. Vancouver remained one of the l a t e s t a r e a s surveyed under O p e r a t i o n Doorstep i n 1964. ( O p e r a t i o n D o orstep was a Lower-M a i n l a n d d r i v e t o f i n d as many t u b e r c u l o s i s cases as p o s s i b l e . The d r i v e was c o o r d i n a t e d by the D i v i s i o n of T.B. C o n t r o l but w i t h g r e a t community p a r t i c i p a t i o n and e n t h u s i a s m ) . Even w i t h the i n c r e a s e d c a s e - f i n d i n g of the e a r l y 1960's t u b e r c u l o s i s f a c i l i t i e s were b e i n g c l o s e d or r e d i r e c t e d . In 1964 - o p e r a t i n g rooms at the W i l l o w Chest C e n t r e were c o n v e r t e d from T.B. s u r g i c a l u n i t s t o c a r d i a c u n i t s and i n the same year the f u l l - t i m e t u b e r c u l o s i s s p e c i a l i s t s t a t i o n e d a t Essondale was removed from h i s p o s i t i o n . By the mid-60's t u b e r c u l o s i s treatment was c e n t r a l i z e d i n Vancouver and r e l i e d m a i n l y on 18 t o 24 month d a i l y c o m b i nation t h e r a p y . P a t i e n t s remained i n h o s p i t a l f o r most of t h e i r t r e a t m e n t . H o s p i t a l i z e d drug t h e r a p y remained the treatment of c h o i c e f o r the next decade. In the D i v i s o n ' s r e p o r t f o r 1971 the p h i l o s o p h y i s c l e a r l y o u t l i n e d : " I t has become apparent t h a t community su r v e y s are l e s s p r o d u c t i v e which w i l l n e c e s s i t a t e a change i n t h i s method of case f i n d i n g . " A l t h o u g h many p a t i e n t s 27 are t r e a t e d w h o l l y 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 the m a j o r i t y 40 r e q u i r e a p e r i o d i n h o s p i t a l . " I n n o v a t i o n s i n t u b e r c u l o s i s chemotherapy were not being r a p i d l y t r a n s f e r r e d t o the B.C. t u b e r c u l o s i s c o n t r o l s i t u a t i o n . However, the pace of change p i c k e d up i n the 1970's as the WCC s h i f t e d from a m a i n l y i n - p a t i e n t c e n t r e f o r t u b e r c u l o s i s treatment t o a main l y o u t - p a t i e n t based treatment system. By 1979 r i f a m p i c i n - b a s e d s h o r t course d a i l y chemotherapy had been i n t r o d u c e d as the o u t - p a t i e n t treatment of c h o i c e a t the WCC r e p l a c i n g the l o n g - c o u r s e methods. The 1980's saw even b o l d e r i n n o v a t i o n and the a p p l i c a t i o n of newer r e s e a r c h f i n d i n g s w i t h the e s t a b l i s h m e n t of the community-based DCHC. 4.3 THE WILLOW CHEST CENTRE: In the 1960's the W i l l o w Chest Centre began t o t r e a t more cases on an o u t - p a t i e n t b a s i s . I n the 1970's treatment at the c e n t r e was c h a r a c t e r i z e d by a growing s h i f t towards o u t - p a t i e n t t h e r a p y as shown i n Table I I I . T A B L E . I l l : Percentage of T.B. O u t - p a t i e n t s a t WCC. (1974-80) YEAR % OF CASES TREATED AS OUTPATIENTS AT THE WCC 1974 55 1975 61 1976 65 1977 68 1978 75 1979 76 1980 78 Source: 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 B r i t i s h Columbia. Annual R e p o r t , 1981. (42) By the l a t e 1970's emphasis was p l a c e d more on p a t i e n t f o l l o w up t o ensure drug c o m p l i a n c e . A f t e r a new-active case was l o c a t e d and p l a c e d on o u t - p a t i e n t t r e a t m e n t , appointments were s e t up 28 u s u a l l y a t q u a r t e r l y i n t e r v a l s (but sometimes monthly or once every 2 months) f o r the p a t i e n t t o come i n f o r m e d i c a l checks and to r e c e i v e h i s / h e r drug s u p p l y . U n t i l 1979, treatment c o n s i s t e d of a d a i l y c o u r s e of INH and PAS or ethambutol a d m i n i s t e r e d f o r 12-24 months. A f t e r 1979, R i f a m p i c i n , ethambutol and INH s h o r t - c o u r s e t h e r a p y a d m i n i s t e r e d f o r an average of 9 months became the s t a n d a r d treatment a t the WCC. While t h i s method of treatment proved f e a s i b l e f o r c o m p l i a n t p a t i e n t s , i t ' s u s e f u l n e s s f o r non-compliant p a t i e n t s remained i n doubt. I n c r e a s i n g l y the id e a of s u p e r v i s e d , community-based s h o r t - c o u r s e i n t e r m i t t e n t therapy f o r the ' d i f f i c u l t - t o - t r e a t ' group (who were mai n l y r e s i d e n t i n the Study Area ) became a t t r a c t i v e . A c c o r d i n g l y , i n 1980 the D i v i s i o n of T.B. C o n t r o l r e q u e s t e d and r e c e i v e d f u n d i n g f o r such a p r o j e c t from the M i n i s t r y of H e a l t h . 4.4 THE DOWNTOWN COMMUNITY HEALTH CLINIC: The Downtown Community C l i n i c T u b e r c u l o s i s Program was s e t up s p e c i f i c a l l y t o t a c k l e the t u b e r c u l o s i s problem i n the Study Are a . The DCHC m a i n l y uses the s u p e r v i s e d s h o r t - c o u r s e i n t e r m i t t e n t ( t w i c e weekly) o u t - p a t i e n t drug regimes which were developed i n d e v e l o p i n g n a t i o n s . T h i s may be p a r t i c u l a r l y a p p r o p r i a t e f o r the t u b e r c u l a r p o p u l a t i o n of the a r e a which i n some ways has c h a r a c t e r i s t i c s of a d e v e l o p i n g c o u n t r y ' s p o p u l a t i o n ( p o v e r t y , bad l i v i n g c o n d i t i o n s ) . T h e DCHC, t h e r e f o r e r e p r e s e n t s the l a t e s t most p r o g r e s s i v e developments i n t u b e r c u l o s i s chemotherapy. The main f i n a n c i a l o u t l a y f o r the program i s the s a l a r y of the 29 T.B. n u r s e . The T.B. nurse i s expected t o e s t a b l i s h a good s u p p o r t i v e r a p p o r t w i t h the c l i e n t s , t o d i r e c t l y s u p e r v i s e T.B. t r e a t m e n t , ( t h i s means t h a t the T.B. nurse a c t u a l l y watches the p a t i e n t i n j e s t the drugs) and go out i n t o the community to f i n d p a t i e n t s when they miss c l i n i c appointments. The t h r u s t of the approach i s s u p p o r t i v e r a t h e r than p u n i t i v e and i t s success may hinge g r e a t l y on the p e r s o n a l i t y of the T.B. nurse. G e n e r a l l y , treatment i s d a i l y or t w i c e weekly u s i n g a com b i n a t i o n of R i f a m p i c i n , INH and V i t a m i n B6. Treatment i s s u p e r v i s e d . That i s , p a t i e n t s come t o the c l i n i c t o r e c e i v e t h e i r m e d i c a t i o n d i r e c t l y i n the T.B. nurse's o f f i c e . The treatment g e n e r a l l y l a s t s 9 months. O u t - p a t i e n t treatment d u r a t i o n v a r i e s depending on the amount of treatment r e c e i v e d as an i n - p a t i e n t ( f o r h o s p i t a l i z e d p a t i e n t s ) and the degree of compliance shown by the p a t i e n t . P h y s i c i a n s at the 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. A c c o r d i n g t o Dr. Chao at the WCC, s e l e c t i o n c r i t e r i a a r e r e s i d e n c e i n the ar e a and p o t e n t i a l non-compliance. That i s , i f s t a f f a t the WCC judge a Study Area p a t i e n t i s a non-c o m p l i e r , they w i l l put him/her on the DCHC program. A person deemed as p o t e n t i a l l y c o m p l i a n t by the WCC s t a f f (even though r e s i d e n t i n the Study Area) may be p l a c e d on o u t - p a t i e n t therapy at the WCC r a t h e r than the DCHC. Thus, the most ' d i f f i c u l t - t o -t r e a t ' t u b e r c u l a r p a t i e n t s r e s i d e n t i n the Study Ares, ,^re t r e a t e d a t the DCHC. The c l i n i c i s faced w i t h one the most c h a l l e n g i n g t u b e r c u l a r p a t i e n t c a s e - l o a d i n the p r o v i n c e . In the next c h a p t e r , the 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 s o c i o -30 demography of the study area i s d e s c r i b e d . 31 CHAPTER 5. THE EPIDEMIOLOGY and SOC10-DEMOGRAPHY of TUBERCULOSIS in the STUDY AREA. 5.1 INTRODUCTION: The purpose of t h i s c h a p t e r i s to d e s c r i b e the major h i g h - r i s k group l i v i n g i n the Study A r e a . Up t o t h i s p o i n t we have d e s c r i b e d the treatment systems these 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 treatment i s s u e s ( p a r t i c u l a r l y compliance) i t i s nec e s s a r y t o d e s c r i b e the p a t i e n t p o p u l a t i o n . Before d e s c r i b i n g the h i g h r i s k group the epi d e m i o l o g y (as f a r as i s p r e s e n t l y known) and socio-demography of the Study Area are o u t l i n e d as background. 5.2 EPIDEMIOLOGY of T.B. in 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 i n c i d e n c e compared t o the p r o v i n c i a l average. Metro-Vancouver r a t e s appear " s t u c k " above the p r o v i n c i a l average. Furthermore, r a t e s w i t h i n the C i t y of Vancouver's N o r t h H e a l t h U n i t and the Study Area are s i g i f i c a n t l y h i g h e r than Metro-Vancouver r a t e s . (Table IV) TABLE IV: Comparison of I n c i d e n c e Rates i n B.C. Metro-Vancouver the N o r t h H e a l t h U n i t , the Study Area and Census T r a c t 58 (the"Downtown-Eastside") d u r i n g the Study Period.( 1 9 7 7 - 8 3 ) YEAR Rate i n Rate i n Metro Rate i n Rate i n Rate i n i n B.C. Vancouver N o r t h U n i t Study Area T r a c t 58 1977 14.9 24 .2 186.7 199.0 1 978 16.4 22 .3 92 .4 228 .9 359.0 1979 15.0 20.0 63 .4 198.7 399.0 1980 15.1 26.1 J 0 8 . 4 (no data) (no data) 1981 14.3 27 .2 H 6 . 9 252.9 399.0 1982 15.2 28.8 1 04 .2 246.9 479.0 1983 95.8 295.0 399.0 • M e t r o p o l i t a n Vancouver inc'. Ludes the municlpa. L i t i e s o Vancouver, Richmond, N o r t h Vancouver, West Vancouver and Burnaby. 32 P a r t i a l Source: 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 B r i t i s h Columbia, Annual R e p o r t s 1977-83. (42) When these r a t e s a re averaged out over the Study P e r i o d the r e s u l t s a r e i n Table V . TABLE V: Comparison of Average Rates (1977-83) i n B.C. Metro-Vancouver, N o r t h H e a l t h U n i t , the Study Area and Census T r a c t 58. PLACE B.C Metro-Van Nt. U n i t Study Area T r a c t 58 RATE 15.2 24.8 97.7 248 .4 372.0 T a b l e V i n d i c a t e s t h a t , f o r the time p e r i o d of t h i s s t u d y , i n c i d e n c e r a t e s w i t h i n the Study Area were 17 times g r e a t e r than the p r o v i n c i a l average and 10 times g r e a t e r than the r a t e s i n M e t r o p o l i t a n Vancouver. F u r t h e r m o r e , w i t h i n Census T r a c t 58, r a t e s averaged 372 per 100,000 which were 50% h i g h e r than the r e s t of the Study Area, 15 times the Metro-Vancouver r a t e s and 25 times the p r o v i n c i a l r a t e s . The r a t e s o b t a i n e d i n t h i s study a r e s i m i l a r t o those o b t a i n e d 21 by "Enarson i n an u n p u b l i s h e d survey of t u b e r c u l o s i s r a t e s i n Vancouver. He e s t i m a t e d t h a t the new-active r a t e of d i s e a s e among Canadian-born white low-income Vancouver slum d w e l l e r s was 242 per hundred thousand i n 1981. (The r a t e s i n T a b l e s IV and V are not l i m i t e d t o the Canadian-born p o p u l a t i o n ) One can use r a t e s when comparing the Study Area w i t h o t h e r l a r g e r a r e a s to get a u s e f u l i d e a of r a t e d i f f e r e n c e s among r e g i o n s . However, when a n a l y z i n g v a r i o u s groups w i t h i n the Study Area 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 reasons: 1 ) , the census data f o r the Study Area i n g e n e r a l and Census T r a c t 58 i n p a r t i c u l a r may be i n n a c u r a t e because of the unknown and s h i f t i n g c h a r a c t e r i s i t c s of the t r a n s i e n t p o p u l a t i o n , 2 ) , t h e r e i s no 33 r e l i a b l e e s t i m a t e f o r the N a t i v e p o p u l a t i o n so t h a t r a t e s f o r Canadian-born N a t i v e s and non-Natives are not c a l c u l a b l e ; 3 ) , the r a t e of change i n the p o p u l a t i o n i s unknown. Between 1961 and 1976 the p o p u l a t i o n i n the Study Area dec r e a s e d by 26% (see s e c t i o n 5.3 f o r a d e t a i l e d d i s c u s s i o n on the socio-demography of the 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 was a w e l l documented phenomena i n the 1960's and 70's. However, the 1981 p o p u l a t i o n of the Study Area was 12% h i g h e r than the 38 1976 f i g u r e (8538 v s . 7623). A 14% i n c r e a s e was r e c o r d e d f o r Census T r a c t 58 f o r the same time p e r i o d . Thus, a t l e a s t over the f i r s t p a r t of the Study P e r i o d , the p o p u l a t i o n was i n c r e a s i n g i n the Study Area. ( I t i s i n t e r e s t i n g t h a t s t u d i e s d u r i n g the economic boom of the 60's and 70's show skid-row emptying a c r o s s N o r t h America. T h i s was t r u e i n Vancouver t o o . But, now s i n c e the economic downturn of the l a t e 70's Vancouver's skid-row p o p u l a t i o n i s i n c r e a s i n g . ) I f t hese census f i g u r e s are a c c u r a t e , then the r a t e s f o r the Study Area and Census T r a c t 58 i n Table IV suggest r e l a t i v e s t a b i l i t y over the Study P e r i o d . High i n c i d e n c e r a t e s i n Metro-Vancouver a r e r e f l e c t e d by h i g h t u b e r c u l o s i s m o r t a l i t y f i g u r e s . For the decade 1961-1970 t h e r e were 238 t u b e r c u l o s i s deaths i n Metro-Vancouver. These were 48.8% of a l l p r o v i n c i a l deaths due t o t u b e r c u l o s i s . The mean annual t u b e r c u l o s i s death r a t e f o r M e t r o p o l i t a n Vancouver i n the decade was 3.5 compared to a p r o v i n c i a l r a t e of 2.7. For the twenty s t a t i s t i c a l areas i n B.C., Metro-Vancouver's death r a t e was 41 topped o n l y by those i n the C a r i b o o and Skeena d i s t r i c t s . D u r i n g the Study P e r i o d , 42.5% (37) of p r o v i n c i a l deaths due t o 34 t u b e r c u l o s i s o c c u r r e d i n the Study Area. The mean annual t u b e r c u l o s i s death r a t e f o r the Study Area over the Study P e r i o d was 37.1 which l i k e the i n c i d e n c e r a t e i s about 10 times h i g h e r than the Metro-Vancouver average death r a t e from t u b e r c u l o s i s . The e p i d e m i o l o g y of T.B. i n Vancouver has been g r e a t l y i n f l u e n c e d by 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 T.B r a t e s , p a r t i c u l a r l y s i n c e 1970. R e c e n t l y (1979-80) the i n f l u x of a p p r o x i m a t e l y 10,000 South East A s i a n immigrants i n t o B.C. have a l s o c o m p l i c a t e d l o c a l T.B. epi d e m i o l o g y and may account f o r 20 much of the h i g h r a t e s i n the Metro-Vancouver r e g i o n . A comparison of the p r o p o r t i o n of Canadian-born v e r s u s non-Canadian born cases o c c u r r i n g i n the Study Area and Census T r a c t 58 h e l p s t o determine the r e l a t i v e c o n t r i b u t i o n of the h i g h - r i s k immigrant group t o the t u b e r c u l o s i s e p i d e m i o l o g y i n the a r e a . (Table VI) ( I t s h o u l d be p o i n t e d out t h a t a c c o r d i n g t o the 1981 census, the Canadian-born and non-Canadian born p o p u l a t i o n of both the Study Area and Census T r a c t 58 were about e q u a l ) TABLE V I : Percentage of Canadian-born and non-Canadian born Cases i n the Study Area and Census T r a c t 58 d u r i n g the Study P e r i o d . YEAR STUDY AREA CENSUS TRACT 58 Can- Born non-CanBorn Can-Born non-CanBorn 1 977 58 42 40 60 1 978 66 34 67 33 1 979 58 42 67 33 1981 45 55 70 30 1 982 56 44 25 75 1 983 78 22 100 000 AVERAGE 60 40 61 .5 38.5 From Table V I , i t i s c l e a r t h a t the p r o p o r t i o n of Canadian v e r s u s non-Canadian born persons i n both the Study Area and 35 Census T r a c t 58 have remained r e l a t i v e l y s t a b l e from 1977-1982 a t r e s p e c t i v e l y 60% and 40%. The p r o p o r t i o n s f o r 1983 show a much g r e a t e r than u s u a l c o n t r i b u t i o n of cases from Canadian-born persons. With t h i s data base t h e r e i s no way t o t e l l whether t h i s i s an a b e r r a t i o n or p a r t of a new t r e n d i n the T.B. e p i d e m i o l o g y of the Study Area. Because the p o p u l a t i o n of Canadian-born and non-Canadian born i n both the Study Area and Census T r a c t 58 a r e a p p r o x i m a t e l y equal these p r o p o r t i o n s suggest t h a t r a t e s are h i g h e r i n the Canadian-born p o p u l a t i o n than the non-Canadian born i n these a r e a s . One might expect h i g h e r r a t e s i n the Canadian-born p o p u l a t i o n i f the N a t i v e c o n t r i b u t i o n were h i g h because r a t e s f o r t h i s segment of the Canadian-born p o p u l a t i o n are known t o be much h i g h e r than r a t e s f o r non-Native Canadians. A comparison of the c o n t r i b u t i o n of N a t i v e s and non-Natives t o the Canadian-born case l o a d of the Study Area was made t o a s s e s s the r e l a t i v e impact of these two groups on Candadian-born r a t e s . (Table V I I ) TABLE V I I : Percentage of N a t i v e s and non-Natives Among Canadian-born cases i n the Study Area and Census T r a c t 58. YEAR STUDY AREA CENSUS TRACT 58 Nat i v e non-Nat i v e Nat i v e non-Nat i v e 1977 44 56 50 50 1978 28 72 50 50 1979 47 53 50 50 1981 37 63 43 57 1982 35 65 67 33 1983 45 55 40 60 AVE. 40 60 50 50 L i k e Table V I , Table V I I shows r e l a t i v e s t a b i l i t y i n the p r o p o r t i o n of cases d i s t r i b u t e d between the two groups. However, 36 u n l i k e the comparison of Canadian-born w i t h non-Canadian-born i n Table V I , t h e r e are d i f f e r e n c e s between the Study Area and Census T r a c t 58. Census 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 of N a t i v e cases than the Study Area i n g e n e r a l . Table V I I a l s o i n d i c a t e s t h a t f o r the Study Area 60% of cases a r i s i n g i n the Canadian-born p o p u l a t i o n d u r i n g the Study P e r i o d were n o n - N a t i v e s . T h i s means h i g h r a t e s among Canadian-born persons i n the Study Area r e c e i v e a s i g n i f i c a n t c o n t r i b u t i o n from non-Native Canadians. What do these r e s u l t s mean i n terms of T.B. e p i d e m i o l o g y of the Study Area? F i r s t l y , they show t h a t t h e r e are t h r e e main h i g h -r i s k groups f o r T.B. i n the a r e a : 1) Urban N a t i v e s , 2) persons born o u t s i d e of Canada, and 3) Non-Natives born i n Canada. Secondly, the r e s u l t s show a s t a b i l i t y i n r e l a t i o n t o time. That i s , the p r o p o r t i o n of cases w i t h i n each of the t h r e e groups has remained f a i r l y c o n s t a n t over the Study P e r i o d 'as have r a t e s . (The year 1977 i s an e x c e p t i o n . For t h i s y e a r , r a t e s were u n u s u a l l y low compared t o the o t h e r f i v e y e a r s under s t u d y . I t i s not known why the r a t e s were lower i n 1977.) T h i r d l y , a p p r o x i m a t e l y 40% of cases d u r i n g the Study P e r i o d were due t o people born o u t s i d e of Canada and 60% due t o Canadian-born persons. The N a t i v e c o n t r i b u t i o n to Canadian-born cases was about 40% so t h a t 60% of Canadian-born cases i n the Study Area were n o n - N a t i v e s . These p r o p o r t i o n s remained s t a b l e over the study p e r i o d , except f o r the year 1983. Whether t h i s year was an anomaly or the b e g i n n i n g of a new t r e n d i s unknown and undeterminable based on the d a t a i n t h i s s t udy. 37 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 i s a problem w i t h i n the Study Area and o u t l i n e s the e p i d e m i ol ogy of T.B. i n terms of the t h r e e main h i g h - r i s k groups i n the a r e a . T h i s s e c t i o n a t t e m p t s to e x p l a i n i n g e n e r a l terms the socio-demography of the Study Area. A r e p o r t on the h e a l t h s t a t u s of census t r a c t s 57,58,and 59 (these 3 census t r a c t s c o i n c i d e e x a c t l y w i t h the Study Area) prepared f o r the Vancouver H e a l t h and P l a n n i n g Departments i n 1978 h i g h l i g h t s the socio-economic and socio-demographic 3 s i t u a t i o n of r e s i d e n t s . (The data from t h i s r e p o r t are based ma i n l y on the 1976 update of the 1971 f e d e r a l census r e p o r t . ) The number of people l i v i n g i n the study area had dropped by 26% between 1961 and 1976 i n d i c a t i n g a f a i r l y steady movement of people out of the a r e a . ( T h i s t r e n d was r e v e r s e d between 1976 and 1981 as the Study Area p o p u l a t i o n i n c r e a s e d by 12%) In terms of age s t r u c t u r e , 27% of study a r e a r e s i d e n t s were 65 y e a r s of age or o l d e r compared t o a Vancouver f i g u r e of 14%. In the Downtown-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 pronounced at 36%. In Vancouver t h e r e i s an a p p r o x i m a t e l y equal r a t i o of males and females. However, f o r the study a r e a 69% of the p o p u l a t i o n i s male and 31% female. T h i s d i f f e r e n c e i n r e l a t i o n t o the r e s t of Vancouver i s even more pronounced i n c o n s i d e r i n g the Downtown-E a s t s i d e where males r e p r e s e n t 85% of the p o p u l a t i o n . In terms of e t h n i c groups the Study Area has a 37% Chinese p o p u l a t i o n compared t o 7% as a whole i n Vancouver and a 32% B r i t i s h - b o r n p o p u l a t i o n compared t o 53% i n the c i t y . I t i s 38 d i f f i c u l t t o o b t a i n an exact a c c o u n t i n g of the n a t i v e p o p u l a t i o n i n the a r e a . T h i s a r e a a l s o c o n t a i n s a l a r g e number of t r a n s i e n t s . E s t i m a t e s of t h i s p o p u l a t i o n are 3,000 of which h a l f are p r o b a b l y n a t i v e . E d u c a t i o n , income and employment l e v e l s are low compared t o c i t y a v e r a g e s . The unemployment r a t e i n the Downtown d i s t r i c t s i s 41% compared t o 11% i n Vancouver and almost 70% of the study area p o p u l a t i o n had incomes l e s s than $3,000 per year compared t o 36% i n Vancouver. For e d u c a t i o n , 62% of study area r e s i d e n t s had o n l y 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 Vancouver. These socio-economic c o n d i t i o n s are a s s o c i a t e d w i t h g e n e r a l i l l h e a l t h i n the Study Area p o p u l a t i o n . Thus, the Study Area has h i g h r a t e s of a l c o h o l and drug abuse p a r t i a l l y r e f l e c t e d i n very h i g h r a t e s of c i r r h o s i s of the l i v e r . In l o o k i n g a t causes of death by a r e a i n Vancouver i n the year 1977 some f a c t s are h i g h l i g h t e d . For example, 22% of male and 23% of female deaths i n the Study Area a r e from r e s p i r a t o r y d i s e a s e compared t o r e s p e c t i v e f i g u r e s of 8% and 5% i n Vancouver. (However, i t s h o u l d be borne i n mind t h a t g r e a t e r age of r e s i d e n t s i n the Study Area may be a c o n t r i b u t i n g f a c t o r . ) The d i f f e r e n c e i n death r a t e s from r e s p i r a t o r y d i s e a s e comprise the s i n g l e b i g g e s t d i f f e r e n c e i n m o r t a l i t y p a t t e r n s between the Study Area and Vancouver. E f f e c t i v e l y , death r a t e s from r e s p i r a t o r y d i s e a s e i n the Study Area a r e 350% h i g h e r than the Vancouver average. ( A g a i n , age s t a n d a r d i z a t i o n would have t o be c v a r i e d out on the death r a t e s to r e f l e c t the t r u e d i f f e r e n c e ) . In summary the r e p o r t s t a t e d : "The Study Area may be d e s c r i b e d , i n comparison t o Vancouver, 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 . In comparison t o Vancouver i t has a h i g h p r o p o r t i o n of o l d e r s i n g l e males, lower l e v e l s of e d u c a t i o n and income and h i g h e r l e v e l s of unemployment. I t i s e t h n i c a l l y a more d i v e r s e 3 area than Vancouver and has a h i g h p r o p o r t i o n of t r a n s i e n t s . " I t must be re-emphasized t h a t between 1976 and 1981 the p o p u l a t i o n of the Study Area i n c r e a s e d by 12% r e v e r s i n g the s k i d -row d e p o p u l a t i o n t r e n d of the 60's and e a r l y 70's. In the p r e v i o u s s e c t i o n i t was shown t h a t t u b e r c u l o s i s r a t e s i n the Study Area and the Downtown-Eastside are the h i g h e s t i n the Metro-Vancouver r e g i o n . In t h i s s e c t i o n i t has been shown t h a t the p o p u l a t i o n of the study area i s o l d e r , poorer and more e t h n i c a l l y d i v e r s e than the r e s t of Vancouver's p o p u l a t i o n . Because the Study Area houses an o l d e r p o p u l a t i o n and a l a r g e p r o p o r t i o n of immigrants, the Area i t s e l f i s l i k e l y t o produce more t u b e r c u l o s i s cases than o t h e r d i s t r i c t s i n Vancouver. Groups a t h i g h - r i s k f o r T.B. a r e c o n c e n t r a t e d i n the Study Area. However, t h i s may not be the o n l y f a c t o r o p e r a t i n g i n T.B. e p i d e m i o l o g y of the a r e a . The p o v e r t y , and poor l i v i n g c o n d i t i o n s of most area r e s i d e n t s are a r i s k f a c t o r i n the endogenous e x a c e r b a t i o n of t u b e r c u l o s i s . O l d e r r e s i d e n t s who are a l c o h o l i c and m a l n o u r i s h e d run a h i g h e r r i s k of r e a c t i v a t i o n than o l d e r w e l l - o f f r e s i d e n t s of Vancouver. N a t i v e s and immigrants may run a g r e a t e r r i s k of r e a c t i v a t i o n i n the d i f f i c u l t l i v i n g c o n d i t i o n s i n the Study Area. Any f a c t o r s which make these l i v i n g c o n d i t i o n s worse may i n c r e a s e the r i s k of endogenous e x a c e r b a t i o n f o r the h i g h - r i s k groups. With t h i s i n mind, r e c e n t developments i n the Study Area i n 40 r e l a t i o n t o Vancouver's W o r l d - F a i r (Expo-86) may a f f e c t the 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 the a r e a . P r o p e r t y developments r e l a t e d t o Expo-86 are d e p o p u l a t i n g and changing the demographic c h a r a c t e r of the Study A r e a . Many of the t u b e r c u l a r p a t i e n t s l i v i n g i n the Study Area l i v e i n f a i r l y run-down h o t e l s which o f t e n t u r n i n t o permanent homes. Many of these h o t e l s are b e i n g renovated t o c a p i t a l i z e on the t o u r i s t i n f l u x expected from Expo-86. A c c o r d i n g t o a survey by the Vancouver Sun i n February 1986, average h o t e l r e n t s i n the downtown area w i l l 48 go up by 600% d u r i n g Expo-86. A c c o r d i n g t o Vancouvers' deputy d i r e c t o r of S o c i a l P l a n n i n g , twenty two of the Downtown-Eastside's 26 h o t e l s are p l a n n i n g r e n o v a t i o n s . A Downtown E a s t s i d e R e s i d e n t s A s s o c i a t i o n survey conducted i n February 1986 p r e d i c t e d about 1,000 rooms w i l l be a f f e c t e d by the r e n o v a t i o n s . C i t y h o u s i n g p l a n n e r John J e s s u p a l s o p r e d i c t e d the s i t u a t i o n w i l l worsen. P r e s e n t l y (February 1986) a t l e a s t 300 downtown r e s i d e n t s have been d i s l o c a t e d 44 and:"The t r e n d has j u s t s t a r t e d . " C l e a r l y , the f u t u r e s o c i o -demographic s t r u c t u r e of the Study Area i s u n c e r t a i n as the a r e a i s i n a s t a t e of f l u x . A p o r t i o n of the t u b e r c u l a r p o p u l a t i o n and the p o p u l a t i o n a t h i g h - r i s k t o t u b e r c u l o s i s has been l i v i n g i n these h o t e l s . Because the C i t y of Vancouver does not have enough s o c i a l h ousing u n i t s t o cope w i t h the l a r g e e f f l u x of people i n v o l v e d i n the e v i c t i o n s two major problems emerge. F i r s t l y , the e v i c t i o n s w i l l l i k e l y b r i n g c o n s i d e r a b l e p e r s o n a l h a r d s h i p and f i n a n c i a l s t r e s s to e v i c t e e s which may i n c r e a s e the r a t e of endogenous e x a c e r b a t i o n of the d i s e a s e . S e c o n d l y , the e v i c t i o n s may i n c r e a s e 41 the t u b e r c u l o s i s r a t e s i n the area as a f o r m e r l y s e t t l e d p o p u l a t i o n of i n f e c t e d people i s e s s e n t i a l l y pushed out onto the s t r e e t t o mingle w i t h the u n i n f e c t e d p o p u l a t i o n . Obvious problems are l i k e l y i n terms of t u b e r c u l o s i s treatment and c a s e - h o l d i n g i n the a r e a . I t may be harder t o keep t r a c k of t u b e r c u l o s i s p a t i e n t s among the e v i c t e e s . The e v i c t i o n s w i l l l i k e l y cause d i f f i c u l t i e s f o r the DCHC's T.B. 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 . In summary, the Study Area i s a depressed a r e a housing a unique p o p u l a t i o n of mai n l y 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 of the are a are a l c o h o l i c and on w e l f a r e . Rents are i n c r e a s i n g i n the area f o r c i n g a f o r m e r l y s e t t l e d group a t h i g h - r i s k f o r t u b e r c u l o s i s (or a l r e a d y w i t h the d i s e a s e ) out of t h e i r homes. The r i s k f o r i n c r e a s e d r a t e s of endogenous e x a c e r b a t i o n of the d i s e a s e among t h i s group i s l i k e l y i n c r e a s e d as i s the r i s k of spread of t u b e r c u l o s i s t o the u n i n f e c t e d p o p u l a t i o n i n the a r e a . 5.4 THE HIGH RISK GROUP: We have d e s c r i b e d T.B. epidemiology and socio-demography i n the Study Area. 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 r a t e s are pr e s e n t i n the area and the area i s a poor d i s t r i c t of Vancouver. The 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 i n g r e a t e r d e t a i l the h i g h r i s k group i n the d i s t r i c t . As background the author attempted f i n d i n f o r m a t i o n on s i m i l a r h i g h - r i s k groups i n o t h e r urban are a s of developed c o u n t r i e s . I n f o r m a t i o n was s p a r s e . What f o l l o w s i s a review of the a v a i l a b l e l i t e r a t u r e . A study by Chapman and D y e r l y i n the e a r l y 1960's i n the U n i t e d 42 S t a t e s r e p o r t e d t h a t crowding, mode of l i v i n g and i n t e n s i t y of exposure were important i n the i n t r a f a m i l i a l t r a n s m i s s i o n of T.B. 1 0 w i t h s e v e r i t y of d i s e a s e the most important f a c t o r . In a 1950 study by Comstock of an urban p o p u l a t i o n i n Alabama and G e o r g i a , non-whites had much g r e a t e r r a t e s of t u b e r c u l o s i s i n f e c t i o n than w h i t e s and men had g r e a t e r r a t e s than women i n f o r 12 both w h i t e s and non-whites. L a t e r , i n 1963, Comstock and Kummerer s t u d i e d urban h i g h - s c h o o l s t u d e n t s i n Washington D.C. and found h i g h r a t e s of t u b e r c u l i n r e a c t i v i t y a s s o c i a t e d w i t h e c o n o m i c a l l y d e p r i v e d and crowded l i v i n g c o n d i t i o n s , household exposure t o 29 T.B., and broken homes. In a more r e c e n t paper (1977) of t u b e r c u l i n r e a c t o r r a t e s among urban a d u l t s i n the U n i t e d S t a t e s , h i g h e r r a t e s were a s s o c i a t e d w i t h non-white r a c i a l s t a t u s , lower income, l e s s 23 e d u c a t i o n , d i v o r c e or s e p a r a t i o n and more crowded r e s i d e n c e s . A 1973 survey of employees ( u s i n g m u l t i v a r i a t e a n a l y s i s ) i n the New York E d u c a t i o n Department found t h a t " t u b e r c u l o s i s i n f e c t i o n i s s i g n i f i c a n t l y a s s o c i a t e d w i t h r a c e , socio-economic 32 s t a t u s , age and sex, i n t h a t o r d e r . " A l l of these s t u d i e s are u s e f u l because they show c l e a r l y t h a t socio-demographic and socio-economic i n d i c a t o r s are a s s o c i a t e d f a i r l y 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 urban p o p u l a t i o n s i n a developed c o u n t r y . Because these s t u d i e s show t h a t t u b e r c u l o s i s i s a s s o c i a t e d w i t h p o v e r t y , low e d u c a t i o n , e t c . i t may come as no s u r p r i s e t h a t T.B. i s l i k e l y l o c a t e d i n the most d e p r i v e d urban r e g i o n s : l i k e s k i d - r o w . Three main s t u d i e s were found d e s c r i b i n g f a c e t s of s o c i o -demography and 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 . In 43 a 1960 study i n New York C i t y , 9,000 homeless skid-row r e s i d e n t s were X-rayed. A t o t a l of 144 cases of new-active cases were found 1 1 among the X-rayed group g i v i n g a r a t e of 1600 per 100,000. A 1969 survey of a B a l t i m o r e c h e s t c l i n i c c a t e r i n g t o a s k i d -row p o p u l a t i o n found a sex and race d i s t r i b u t i o n of 65:35 f o r r e s p e c t i v e l y men and women and non-whites and w h i t e s . S i x t y - f i v e p e rcent of the c l i n i c a t t e n d e e s were non-white even though the 23 urban area was 43% non-white. (Note, i n our Study Area the whi t e to non-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 the white t o non-white r a t i o a t the DCHC was about 60:30. F i n a l l y , a 1971 Danish study based on the n a t i o n a l D a nish t u b e r c u l o s i s case r e g i s t r y f o r the y e a r s 1960-68 attempted t o d e f i n e the major h i g h - r i s k groups i n Denmark i n socio-demographic 26 terms. T h i s study showed t h a t i n Copenhagen d i v o r c e d men over f o r t y y e a r s of age had r a t e s which were a p p r o x i m a t e l y 200 per 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 group. Furthermore, the study d e f i n e d an urban group of " l o n e l y men" between the ages of 40 and 69 who were e i t h e r s i n g l e , d i v o r c e d or widowed. Alt h o u g h t h i s group of u r b a n i z e d " l o n e l y men" comprised 11% of the a d u l t male p o p u l a t i o n they c o n t r i b u t e d 33% of the t u b e r c u l o s i s c a s e s . For t h i s group the i n c i d e n c e r a t e f o r t u b e r c u l o s i s was 160 per 100,000. The study c o n c l u d e d by s t a t i n g m a r i t a l s t a t u s may be an important r i s k f a c t o r a s s o c i a t e d w i t h t u b e r c u l o s i s i n c i d e n c e . Based on these s t u d i e s i t i s c l e a r t h a t urban groups ( i n developed c o u n t r i e s ) a t h i g h r i s k f o r T.B. tend t o c o n s i s t of a d i s p r o p o r t i o n a t e number of male, non-white, s i n g l e , people of 44 low socio-economic s t a t u s . When the data g a t h e r e d f o r a l l the cases i n t h i s study are a n a l y s e d a c c o r d i n g t o socio-demographic and socio-economic i n d i c a t o r s t h i s b a s i c p a t t e r n i s c l e a r l y o b s e r v a b l e f o r the Vancouver skid-row t u b e r c u l a r p o p u l a t i o n . (See Table V I I I ) From t h i s t a b l e a socio-demographic p r o f i l e of the h i g h - r i s k group w i t h t u b e r c u l o s i s l i v i n g i n the Study Area can be drawn. Where p o s s i b l e , the p r o p o r t i o n of T.B. cases r e l a t i v e t o s o c i o -demography of the Study Area 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 of Study Area T.B. Cases R e g i s t e r e d i n the ye a r s 1977-79 & 1981-83. (234 Cases) V a r i a b l e Catagory T.B CASE % % i n Study Area RACE White 54 Nat i v e 24 Chinese 22 37 SEX Male 78 66 Female 22 34 AGE 20-59 64 53 60 + 36 36 MARITAL M a r r i e d 23 STATUS S i n g l e 48 Wid & D i v . 29 ALCOHOLIC Yes 72 No 28 OCCUPATION Employed 20 Unemployed 62 41 R e t i r e d 18 BIRTHPL. Canada 63 49 Not Canada 37 51 Table V I I I inr'lc a t e s t h a t compared t o the Study Area p o p u l a t i o n , a g r e a t e r p r o p o r t i o n of males, a g r e a t e r p r o p o r t i o n of Canadian-born and a g r e a t e r p r o p o r t i o n of those i n age-group 20-59 are found i n the t u b e r c u l a r p o p u l a t i o n of the Study A r e a . 45 T h i s may i n d i c a t e t h a t even w i t h i n t h i s h i g h - r i s k area of Vancouver, men, people between the ages 20-59 and Canadian-born are a t g r e a t e r r i s k than the average p o p u l a t i o n f o r T.B. However, these d i f f e r e n c e s may occur because of the i n n a c c u r a c y of the census d a t a f o r 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 i n a b i l i t y t o count the t r a n s i e n t p o p u l a t i o n . (And p a r t i c u l a r l y as the t r a n s i e n t p o p u l a t i o n i s l i k e l y between the ages of 20-59, male and Canadian-born.) In summary, Chapter 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 i s h i g h i n Vancouver compared t o the r e s t of B.C. and t h a t r a t e s i n c r e a s e i n a g r a d i e n t as we go from the N o r t h H e a l t h U n i t t o the Study Area t o the Downtown-Eastside. Moreover, c o n d i t i o n s of p o v e r t y are endemic i n the Study Area and may c o n t r i b u t e t o h e i g h t e n e d r i s k 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 l i v i n g * t h e r e . The Study Area p o p u l a t i o n i n c r e a s e d between 1976 and 1981, so t h a t i n c r e a s e s i n r a t e s noted f o r the Study P e r i o d may be a r e f l e c t i o n of t h i s p o p u l a t i o n s h i f t . I f so, then r a t e s were r e l a t i v e l y s t a b l e throughout the Study P e r i o d i n the Study A r e a . Recent development i n the Study Area r e l a t e d t o Expo-86 may be of p a r t i c u l a r concern because of e v i c t i o n s i n the a r e a . The s t r e s s a s s o c i a t e d w i t h e v i c t i o n s may weaken the r e s i s t a n c e of the i n f e c t e d p o p u l a t i o n l e a d i n g to a h i g h e r r a t e of r e a c t i v a t i o n . The e v i c t i o n s may a l s o i n c r e a s e the r i s k of primary i n f e c t i o n f o r the l o c a l u n i n f e c t e d p o p u l a t i o n as a h i t h e r t o f a i r l y s e t t l e d p o p u l a t i o n of h o t e l r e s i d e n t s i s m o b i l i z e d to f i n d a l t e r n a t e accomodation. Canadian-born persons c o n t r i b u t e about 60% of the cases i n the 46 Study A r e a . 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 N a t i v e v e r s u s non-Native cases t o the h i g h Canadian-born c o n t r i b u t i o n , i t i s c l e a r t h a t non-Native cases occur 1.5 times as o f t e n as N a t i v e c a s e s . T h i s i s an unusual r a t i o because based on average p r o v i n c i a l r a t e s f o r N a t i v e and non-Native Canadian-born persons we would expect the number of N a t i v e cases t o be a t l e a s t 17 times the number of non-Native cases assuming an e q u a l p o p u l a t i o n of N a t i v e s and n o n - N a t i v e s . ( T h i s i s based on a B.C. r a t e of 110/100,000 f o r N a t i v e s and 9.7/100,000 f o r n o n - N a t i v e s ) Rates 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 immigrants from c o u n t r i e s w i t h h i g h r a t e s . Thus, i t i s not s u r p r i s i n g t o f i n d members of these two groups c o n t r i b u t i n g t o the T.B. case l o a d i n the Study Area. However, r a t e s f o r non-Native Canadians are g e n e r a l l y low (about 10/100,000 i n B.C.). C l e a r l y , the non-N a t i v e Canadian h i g h - r i s k group i n the Study Area i s a unique group. A l t h o u g h s t u d i e s of T.B. e p i d e m i o l o g y i n s k i d - r o w a r e a s i n developed c o u n t r i e s are few and f a r between, s t u d i e s i n Denmark, and the 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 out the e x i s t e n c e of t h i s 'down-and-out' l o c a l - b o r n group a t h i g h - r i s k f o r the d i s e a s e . T h i s study shows the c o n t r i b u t i o n of non-Native Canadian-born persons i n Vancouver. I t i s h i g h l y l i k e l y t h a t t h i s group has s i g n i f i c a n t impact t o the T.B. e p i d e m i o l o g y of most major N o r t h American c i t i e s . 47 CHAPTER 6: COMPLIANCE 6.1 COMPLIANCE AND SOCIO-DEMOGRAPHY: The data i n Table V I I I show who i s diagnosed as t u b e r c u l a r i n the Study A r e a . P r i o r t o e s t a b l i s h m e n t of the DCHC most members of t h i s t u b e r c u l a r p o p u l a t i o n would have been t r e a t e d at the WCC. However, s i n c e e s t a b l i s h m e n t of the DCHC, c l i n i c i a n s have s e l e c t e d who they f e e l a r e the d i f f i c u l t - t o - t r e a t sub-group w i t h i n t h i s skid-row t u b e r c u l a r p o p u l a t i o n f o r o u t - p a t i e n t t h e r a p y at the DCHC. I t i s c l e a r t h a t t h i s group of p e r c e i v e d n o n - c o m p l i e r s has c e r t a i n socio-demographic f e a t u r e s which d i f f e r e n t i a t e i t from the main body of t u b e r c u l a r p a t i e n t s i n the Study A r e a . (Table IX) TABLE IX. Socio-demographics of WCC and DCHC p a t i e n t s (81-83) _ l CLINIC s o c i o - CLINIC DEMOGRAPHY WCC DCHC # % # SEX Male 19 61 66 87 Female 1 2 39 10 1 3 RACE White 10 32 44 58 Nat i v e 2 7 25 33 Chinese 15 48 7 9 Other 4 13 BIRTHPLACE Canada 9 29 58 76 China 5 16 6 8 S.E. A s i a 1 3 42 1 1 Europe 4 13 9 1 2 Unknown 2 3 ALCOHOLIC No 19 61 15 20 Yes 4 13 56 74 Unknown 8 26 5 6 48 Table IX shows t h a t compared t o the WCC the DCHC t r e a t s ; a g r e a t e r p r o p o r t i o n of Canadian-born p a t i e n t s (76% vs 2 9 % ) , n a t i v e s ( 3 3 % vs 7%), a l c o h o l i c s (74% vs 13%) , and a g r e a t e r p r o p o r t i o n of males (87% vs 61%). A l s o , compared t o the WCC the DCHC t r e a t s a s m a l l e r p r o p o r t i o n of Chinese and S.E. A s i a n born p a t i e n t s (9% vs 58%). These data show t h a t the best p e r c e i v e d c o m p l i e r s i n the t u b e r c u l a r p o p u l a t i o n of the Study Area belong t o the Chinese or South-East A s i a n born group. The Canadian-born p o p u l a t i o n , p a r t i c u l a r l y N a t i v e s , a r e p e r c e i v e d as the most non-compliant group. The p o i n t of t h i s d a t a a n a l y s i s i s t o show t h a t p a t i e n t s a r e s e l e c t e d i n t o the DCHC program on the b a s i s of t h e i r p r o b a b l e compliance as judged by c l i n i c i a n s a t the D i v i s i o n of T.B. 22 C o n t r o l . A c c o r d i n g t o Dr. Enarson, whether a p a t i e n t i s h o s p i t a l i z e d or not and h i s / h e r l e n g t h of h o s p i t a l i z a t i o n i s o f t e n r e l a t e d t o p e r c e i v e d c o m p l i a b i l i t y of the p a t i e n t . Thus, both i n - p a t i e n t and o u t - p a t i e n t treatment m o d a l i t i e s a r e determined i n 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 i n d i v i d u a l c o m p l i a b i l i t y . C l i n i c i a n s may use socio-demographic c r i t e r i a t o s e l e c t p a t i e n t s or they may use some o t h e r c r i t e r i a . I f they s e l e c t p a t i e n t s i n t o a ' d i f f i c u l t - t o - t r e a t ' group on the b a s i s of s o c i o -demographics then c l i n i c a l e x p e r i e n c e i s t e l l i n g them t h a t s o c i o -demography and compliance are l i n k e d . Even i f they s e l e c t t h e i r p e r c e i v e d non-compliant group on an o t h e r - t h a n socio-demographic b a s i s , the end r e s u l t i s s o c i o - d e m o g r a p h i c a l l y d i f f e r e n t c o m p l i e r groups. Thus, socio-demographics a r e somehow l i n k e d t o p e r c e i v e d 49 compliance performance of t u b e r c u l o s i s o u t - p a t i e n t s . While the study data may show a l i n k between socio-demography and compliance - what about the l i t e r a t u r e ? The l i t e r a t u r e on compliance i s e x t e n s i v e . From t h i s body of l i t e r a t u r e and h i s own r e s e a r c h Becker developed a model of 5 compliance. ( F i g 2) FIGURE 2: HEALTH BELIEF MODEL P e r c e p t i o n about h e a l t h M o d i f y i n g f a c t o r s Compliant B e h a v i o r I I I I M o t i v a t i o n Demographic L i k l i h o o d of P e r c e i v e d V a l u e of S t r u c t u r a l compliance t o the I l l n e s s t h r e a t r e d u c t i o n P s y c h o l o g i c a l drug regime. P e r c e p t i o n of how w e l l compliance w i l l reduce i l l n e s s t h r e a t The model s t a t e s t h a t r e a d i n e s s t o undertake c o m p l i a n t behaviour depends on m o t i v a t i o n and b e l i e f i n how w e l l the com p l i a n t behaviour w i l l reduce the i l l n e s s . Socio-demographic f a c t o r s a r e seen as m o d i f y i n g components a f f e c t i n g p e r c e p t i o n s about h e a l t h which i n t u r n determine the l i k l i h o o d of c o m p l i a n c e . T h i s model i s w i d e l y a c c e p t e d and quoted i n the compliance l i t e r a t u r e and p r o v i d e s some t h e o r e t i c a l r a t i o n a l e l i n k i n g compliance and socio-demography. 6.2 ATTENDANCE COMPLIANCE: There are two types of compliance d i s c u s s e d i n the l i t e r a t u r e : 31 attendance and treatment c o m p l i a n c e . Attendance compliance i s concerned e n t i r e l y w i t h a t t e n d a n c e t o appointments w h i l e treatment compliance t a c k l e s the i s s u e of p a t i e n t adherence t o a recommended program of t r e a t m e n t . In t h i s s tudy, the focus i s m a i n l y on attendance compliance f o r two reasons: 1) Attendance compliance measurement i s one t h a t 50 has r e l a t i v e l y few problems compared w i t h measurement of treatment c o m p l i a n c e ; and 2) f o r the DCHC, where treatment i s s u p e r v i s e d , attendance compliance i s the same as treatment compliance (because when a p a t i e n t a t t e n d s the c l i n i c i n j e s t i o n of drugs i s d i r e c t l y m o n i t o r e d ) . W h i l e attendance compliance i s e a s i e r t o measure than treatment compliance i t doesn't r e v e a l as much about treatment outcome as treatment c o m p l i a n c e . A l l t h a t i s b e i n g measured i s atte n d a n c e t o the c l i n i c . For outcomes t o be s u c c e s s f u l , the c l i n i c must f u n c t i o n w e l l . In a c l i n i c e v a l u a t i o n based on attendance c o m p l i a n c e as the dependent v a r i a b l e (such as t h i s study) the assumption i s made t h a t r e g u l a r attendance i s the minimum p r e r e q u i s i t e f o r s u c c e s s f u l outcome. ( I f the p a t i e n t won't come t o the c l i n i c r e g u l a r l y t o p i c k - u p m e d i c a t i o n s then even i f the c l i n i c i s the best t u b e r c u l o s i s c l i n i c i n e x i s t e n c e , treatment w i l l be a f a i l u r e . ) For the p o p u l a t i o n i n the Study Area w i t h i t ' s h i g h p r o p o r t i o n of a l c o h o l i c s and ' d i f f i c u l t - t o - t r e a t ' p a t i e n t s , e n s u r i n g a ttendance i s p a r t i c u l a r l y i m p o r t a n t . In summary, a l t h o u g h the primacy of socio-demographic v a r i a b l e s i n d e t e r m i n i n g compliance t o treatment i s open t o i n t e r p r e t a t i o n i t i s c l e a r t h a t c l i n i c i a n s at the D i v i s i o n of T.B. C o n t r o l s e l e c t out a group they deem as 'non-compliant' which i s s o c i o - d e m o g r a p h i c a l l y d i f f e r e n t from the r e s t of the Study Area p o p u l a t i o n . A n a l y s i n g compliance i n r e l a t i o n t o s o c i o -demographic c h a r a c t e r i s t i c s of 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 dependent v a r i a b l e f o r t h i s study i s attendance compliance because i t i s measureable and because e n s u r i n g r e g u l a r c l i n i c a ttendance i s a p r e r e q u i s i t e f o r c l i n i c s u c c e s s . 5 2 CHAPTER 7. THE EFFECT OF TWO TYPES OF CLINIC SYSTEMS ON COMPLIANCE TO TUBERCULOSIS CHEMOTHERAPY METHODS 7.1 OVERVIEW: The study design is divided into four parts. Parts 1-3 answer the three questions posed in this thesis and part 4 analyses the 'drop-outs' from the DCHC. Part 1 is the evaluative component of the thesis. It is a retrospective matched case-control study to test the n u l l hypothesis that the rate of compliance for patients attending the DCHC equals the rate of compliance for matched controls who attended the WCC. For this section the control group i s the group which attended the WCC in the three year period prior to establishment of the DCHC and the experimental group is the group which attended the DCHC in the three year period after i t ' s establishment. Part 1 i s concerned with a matched comparison of WCC and DCHC patients over two time periods. Parts 2 and 3 are focused en t i r e l y on the DCHC. Part 2 determines which independent variables best explain and predict compliance for patients treated at the DCHC. In Part 3 the sociodemographic and treatment variables for the 4 compliance quartiles at the DCHC are compared. From this coxr-parison a sociodemographic and treatment p r o f i l e for least versus most compliant patients i s developed. In Part 4 the number and chara c t e r i s t i c s of 'drop-outs' from the DCHC program are analyzed. The preceeding analysis in terms of a t t e ndance compliance g i v e s us no i n f o r m a t i o n on the drop-out r a t e from the DCHC. P a r t 4 attempts t o f i l l t h a t gap. With t h i s methodology the DCHC's e f f e c t i v e n e s s i n r e l a t i o n t o the WCC i s determined; major f a c t o r s p r e d i c t i n g compliance at the DCHC a r e determined; and, a p r o f i l e i s developed f o r co m p l i a n t and non-compliant p a t i e n t s . 7.2 SAMPLE: 1. Sample S e l e c t i o n : The p a t i e n t s i n t h i s study were a l l the new a c t i v e t u b e r c u l o s i s cases r e s i d e n t i n census t r a c t s 57, 58 and 59 at time of d i a g n o s i s i n the y e a r s 1977, 78, 79, 81, 82 and 1983. Because t h e r e i s a l e g a l requirement t o r e g i s t e r a l l a c t i v e cases of t u b e r c u l o s i s w i t h the D i v i s i o n of T.B. C o n t r o l , a l l known cases i n the area a re on r e c o r d w i t h the D i v i s i o n . Cases were found u s i n g a master l i s t of Vancouver p a t i e n t s . Each p a t i e n t s ' T.B. ' f i l e was p u l l e d t o see i f the address a t time of d i a g n o s i s was w i t h i n the study a r e a . In t o t a l , 234 cases were found f o r the stud y . The sample was d i s t r i b u t e d as shown i n Table X. Of the 234 e l i g i b l e c a s e s , 78% (182) p a r t i c i p a t e d i n out -p a t i e n t drug t h e r a p y , 16% (38)) d i e d and 6% (13) d i d not p a r t i c i p a t e as o u t - p a t i e n t s because they e i t h e r d i s a p p e a r e d , moved away or were t r e a t e d as i n - p a t i e n t s at WCC. 54 TABLE X: Treatment S t a t u s of T.B. Cases i n the Study Area by Year. REATMENT STATUS 1 977 1978 YEAR 1 979 1981 1 982 1 983 Outpat. a t WCC 20. 31 24 12 7 12 Outpat. a t DCHC 16 29 31 I n p a t i e n t o n l y 2 1 1 DIED 7 6 7 1 0 3 5 DISAPPEARED 2 1 1 LEFT STUDY AREA 2 2 1 TOTAL 31 38 33 42 41 49 2. Sample B o u n d a r i e s . The f o r m a l b o u n d a r i e s of the study were census t r a c t s 57, 58 and 59. These S t a t i s t i c s Canada census t r a c t s encompass the Vancouver d i s t r i c t s of S t r a t h c o n a , the Downtown c o r e and *the Downtown-Eastside and a l s o c o r r e s p o n d t o the N o r t h e r n , Western and Southern b o u n d a r i e s of the Nor t h H e a l t h U n i t of Vancouver's H e a l t h Department.(See map i n Appendix A) These b o u n d a r i e s were choosen because they encompass the DCHC's p a t i e n t t a r g e t a r e a . The DCHC was e s t a b l i s h e d t o s e r v e r e s i d e n t s of the downtown d i s t r i c t s i n Vancouver. A l s o , the boundaries were choosen because S t r a t h c o n a , the Downtown c o r e and Downtown-Eastside have the h i g h e s t r a t e s of t u b e r c u l o s i s i n the c i t y and the because n e a r l y a l l the TB deaths i n Vancouver over the p a s t decade have o c c u r r e d i n these t h r e e d i s t r i c t s . 55 7.3 VARIABLES: T h e d e p e n d e n t v a r i a b l e i n t h i s s t u d y i s c o m p l i a n c e ; t h e i n t e r v e n i n g v a r i a b l e i s t h e o u t - p a t i e n t t r e a t m e n t s y s t e m (DCHC o r W C C ) ; a n d t h e i n d e p e n d e n t v a r i a b l e s c o n s i s t o f m e a s u r e a b l e 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 c h a r a c t e r i s t i c s o f t h e t u b e r c u l a r p o p u l a t i o n . 1.Independent V a r i a b l e s . ( d e t a i l s o n c a t e g o r i e s f o l l o w ) A ) S o c i o - d e m o g r a p h i c . a ) S e x b ) B i r t h p l a c e c ) A g e d ) R a c e . e ) M a r i t a l S t a t u s . f ) O c c u p a t i o n . g ) L o c a t i o n . B ) M e d i c a l V a r i a b l e s . a ) D i a g n o s i s . b ) W h e t h e r h o s p i t a l i z e d p r i o r t o o u t - p a t i e n t t r e a t m e n t . c ) I f h o s p i t a l i z e d - f o r how l o n g . d ) I f h o s p i t a l i z e d - l e n g t h o f i n t e r v a l b e t w e e n d i s c h a r g e a n d f i r s t d r u g p i c k - u p a s a n o u t - p a t i e n t . e ) 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 . f ) A l c o h o l i s m . I n f o r m a t i o n o n s e v e n o f t h e e i g h t s o c i o - d e m o g r a p h i c v a r i a b l e s a r e r e c o r d e d o n a s t a n d a r d i z e d T B 4 0 f o r m w h i c h i s f i l l e d o u t a t e a c h o u t - p a t i e n t v i s i t t o t h e WCC . B e c a u s e a l l p a t i e n t s a t t h e DCHC a r e r e f e r r e d f r o m t h e WCC, t h e y t o o h a v e a T B 4 0 f o r m 56 c o n t a i n i n g t h i s i n f o r m a t i o n on f i l e a t the D i v i s i o n of T.B. C o n t r o l . A l c o h o l i s m or drug a d d i c t i o n a re not a s t a n d a r d p a r t of the T.B. 40 form so r e c o r d i n g of t h i s socio-demographic v a r i a b l e was l e s s r e g u l a r than the oth e r v a r i a b l e s . However, t h i s was l e s s of a problem 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 r e g u l a r l y d i s c u s s e d i n the h o s p i t a l d i s c h a r g e summary. One of the m e d i c a l v a r i a b l e s , d i a g n o s i s i s a l s o r e c o r d e d on the TB 40 form. However, the o t h e r m e d i c a l v a r i a b l e s were t r a n s c r i b e d from the 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 V a r i a b l e s . The i n t e r v e n i n g v a r i a b l e i s type of o u t - p a t i e n t t r e a t m e n t . In the sample, p a t i e n t s e i t h e r d i e d , l e f t the ar e a a f t e r d i a g n o s i s , o b t a i n e d a l l treatment as an i n - p a t i e n t or a t t e n d e d o u t - p a t i e n t treatment at the WCC or DCHC. Thus, o u t - p a t i e n t s ( w i t h one e x c e p t i o n , a man undergoing cancer chemotherapy who a l s o r e c e i v e d o u t - p a t i e n t t u b e r c u l o s i s t h e r a p y from h i s p r i v a t e p h y s i c i a n ) a t t e n d e d the WCC or DCHC. 3.Dependent V a r i a b l e s . Attendance compliance t o o u t - p a t i e n t treatment i s the dependent v a r i a b l e . Compliance i s measured i n terms of attendance a t drug p i c k - u p appointments. In terms of attendance t o appointments, compliance was c a l c u l a t e d by d i v i d i n g a c t u a l a t t e n d a n c e s by expected appointment a t t e n d a n c e s and m u l t i p l y i n g by 100 to g i v e a percentage compliance f i g u r e f o r each patinB>i. Length of out -p a t i e n t treatment was measured i n weeks from the date of the f i r s t 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 out t h a t the number of expected attendances 57 at both c l i n i c s d i f f e r e d enormously. At the WCC drug p i c k - u p appointments were monthly, every two months or q u a r t e r l y . Thus over a treatment course of ni n e months the expected number of appointments v a r i e d from a maximum of nine t o a minimum of t h r e e . At the DCHC, the number of expected drug p i c k - u p appointments depended on the treatment regime recommended. For a d a i l y treatment regime the number of expected c l i n i c a t t e n d a n c e s over n i n e months was a p p r o x i m a t e l y one hundred and e i g h t y . However, someone on a weekly treatment regime would be expected to a t t e n d t h i r t y s i x appointments over a n i n e month span. C l e a r l y , attendance 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 the two c l i n i c s and w i t h i n the DCHC a c r o s s treatment m o d a l i t i e s . Attendance compliance was measured at both c l i n i c s over a maximum o u t - p a t i e n t treatment l e n g t h of 12 months because t h i s was the minimum l e n g t h of o u t - p a t i e n t treatment p r e s c r i b e d f o r the WCC f o r the p e r i o d 1977--79. Thus, appointments o c c u r i n g a f t e r a person had been i n o u t - p a t i e n t therapy at e i t h e r c l i n i c f o r more than 12 months were not i n c l u d e d i n the compliance s c o r e s . 7.4 CODING Data were t r a n s f e r r e d from the T.B. r e c o r d s t o a s p e c i a l l y d e s i gned data c o l l e c t i o n form. N i n e t y percent of the data t r a n s f e r was performed by a r e s e a r c h a s s i s t a n t employed by the U n i v e r s i t y of B.C. (U.B.C) The re m a i n i n g 10% was performed by the a u t h o r . A l l the data c o d i n g and computer e n t r y were performed by the author 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 . Once a l l the data were coded a frequency d i s t r i b u t i o n was run f o r a l l v a r i a b l e s . In o r d e r to c a r r y out the a n a l y s i s some of the data were 58 recoded. Recoded independent v a r i a b l e s were: L o c a t i o n : The a p p r o x i m a t e l y 100 s t r e e t names and 200 s t r e e t numbers were recoded i n t o 4 areas based on p r o x i m i t y t o the DCHC (see map i n Appendix B ) . The r a t i o n a l e behind r e c o d i n g a r e a s was t h a t p r o x i m i t y t o the c l i n i c may a f f e c t c l i n i c a t t e n d a n c e because the p o p u l a t i o n under study i s poor and may have r e s t i t c t e d a c c e s s t o t r a n s p o r t a t i o n . Two a r e a s , each 18 square b l o c k s were c o n s t r u c t e d i n c o n c e n t r i c squares around the DCHC. These area s 1 and 2 a r e the co r e and o u t e r - c o r e a r e a s c l o s e s t t o the c l i n i c . A l s o , these two are a s encompass the DCHC T.B. nur 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 h a l f the Study Area. T h i s 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 i n f l u e n c i n g the compl i a n c e of pat i e n t s . A t h i r d a r e a -area 3- encompasses the e a s t e r n and western edges of the b o u n d a r i e s . Area 4 i s f a r t h e s t from the c l i n i c i n the south-west c o r n e r of the study a r e a . Independent v a r i a b l e s c o n s i s t i n g of i n t e r v a l d a t a l i k e age, l e n g t h of h o s p i t a l i z a t i o n , and i n t e r v a l between h o s p i t a l d i s c h a r g e and f i r s t drug p i c k - u p were recoded i n t o 5 o r d i n a l c a t e g o r i e s . These c a t e g o r i e s were c o n s t r u c t e d so as to 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 the c u m u l a t i v e percentage i n t e r v a l s of twenty p e r c e n t . These worked out as f o l l o w s : Age: 1) 1 through 41 2) 42 through 50 59 3) 51 through 59 4) 60 through 67 5) g r e a t e r than 68. Length of H o s p i t a l i z a t i o n : ( i n weeks) 1) 1 through 6 2) 7 through 13 3) 14 through 17 4) 18 through 24 5) g r e a t e r than 25 weeks. I n t e r v a l between D i s c h a r g e and Drug Pic k - U p : ( i n weeks) 1 ) 1 2) 2 through 5 3) 6 through 9 4) 10 through 13 5) g r e a t e r than 14 weeks. Length of o u t - p a t i e n t t r e a t m e n t : ( i n weeks) 1) 1 through 27 2) 28 through 38 3) 39 through 50 4) 51 through 60 5) g r e a t e r than 61 weeks. Independent v a r i a b l e s c o n s i s t i n g of c a t e g o r i c a l data were recoded as f o l l o w s : O c c u p a t i o n : 1) unemployed 2) r e t i r e d 3) employed. 60 M a r i t a l s t a t u s : 1) S i n g l e 2) M a r r i e d 3) Widowed and d i v o r c e d . D i a g n o s i s : 1) Far advanced a c t i v e 2) M o d e r a t e l y advanced a c t i v e 3) M i n i m a l l y advanced a c t i v e 4) 0 t h e r . (eg.) extra-pulmonary T.B. Dependent V a r i a b l e : P e r c e n t c o m p l i a n c e : 1) 1 t hrough 24 2) 25 through 50 3) 51 through 73 4) 74 t h r o u g h 99 5) 100 % co m p l i a n c e . 7.5 DESIGN BIAS A p o t e n t i a l sources of b i a s a r i s e s because data c o l l e c t i o n was c a r r i e d out by two p e o p l e . A U.B.C. employeee g a t h e r e d most of the d a t a . However, the auth o r g a t h e r e d data f o r 25 o u t s t a n d i n g c a s e s , ( l e s s than 10%). To t e s t the r e l i a b i l i t y of data c o l l e c t i o n between the two p e o p l e , the author randomly s e l e c t e d ten c a s e s p r o c e s s e d by the U.B.C. employee and t r a n s f e r r e d d ata from the r e c o r d s t o the da t a c o l l e c t i o n s h e e t . D i s c r e p a n c i e s between the two s e t s of 10 data sh e e t s were r e c o r d e d and C h i -Square t e s t performed. No s i g n i f i c a n t d i s c r e p a n c i e s were o b s e r v a b l e between the 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 6 1 volume and d e t a i l of T.B. r e c o r d s . In p a r t i c u l a r , p a t i e n t s who have 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 as p a r t of t h e i r T.B. r e c o r d . 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 a s o c i a l worker's assessment on f i l e . These expanded T.B. f i l e s p r o v i d e a more d e t a i l e d socio-demographic and m e d i c a l p r o f i l e than i s a v a i l a b l e f o r n o n - h o s p i t a l i z e d p a t i e n t s . 7.6STUDY DESIGN 1.Question 1. A r e t r o s p e c t i v e matched-case c o n t r o l study t o e v a l u a t e the e f f e c t i v e n e s s of the DCHC i n terms of co m p l i a n c e . A ) P o p u l a t i o n and S e t t i n g . P h y s i c i a n s e l e c t i o n l a r g e l y on the b a s i s of p e r c e i v e d c o m p l i a b i l i t y means t h a t the WCC and the DCHC t r e a t very d i f f e r e n t groups of p a t i e n t s . ( S e e Table IX) C l e a r l y , s e l e c t i o n of p a t i e n t s on the b a s i s of p e r c e i v e d c o m p l i a b i l i t y has r e s u l t e d i n two s o c i o - d e m o g r a p h i c a l l y d i s t i n c t sub-groups of t u b e r c u l o s i s o u t - p a t i e n t s a t t e n d i n g each c l i n i c . Because the treatment groups a t the two c l i n i c s are so d i s s i m i l a r , these two groups cannot be used t o measure the e f f e c t of c l i n i c type on co m p l i a n c e . To m e a n i n g f u l l y compare the e f f e c t of both c l i n i c s on compliance i t was nec e s s a r y t o r e t r o s p e c t i v e l y match cases a t t e n d i n g the DCHC w i t h WCC ca s e s i n terms of major s o c i o -demographic 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 were sought among the 75 cases a t the WCC i n the 1977-79 p e r i o d . Once matched, d i f f e r e n c e s i n compliance between the two groups a re much more l i k e l y due to the i n t e r v e n i n g v a r i a b l e , o u t - p a t i e n t treatment 62 t y p e , than t o s o c i a l background. The c o n t r o l group was the 75 cases a t the WCC i n the 1977-79 p e r i o d and the e x p e r i m e n t a l group was the 76 cases at the DCHC i n the p e r i o d 1981-83 . B ) M a t c h i n g . The 76 DCHC p a t i e n t s were d i v i d e d i n t o groups on the b a s i s of sex, race and b i r t h p l a c e . The same procedure was done f o r the 75 p a t i e n t s who a t t e n d e d the WCC from 1977-79 . These groups were matched. W i t h i n these exact matchings f o r sex, race and b i r t h p l a c e cases were matched ( p a i r - w i s e ) i n or d e r and a c c o r d i n g t o the f o l l o w i n g p r o c e s s : 1. Age - was matched w i t h i n 5 y e a r s of the DCHC p a t i e n t . 2. A r e a - was matched t o w i t h i n 1 d i s t r i c t . 3. A l c o h o l i s m - a l c o h o l i c s were matched w i t h a l c o h o l i c s and non-a l c o h o l i c s were matched w i t h n o n - a l c o h o l i c s or unknowns. 4. D i a g n o s i s - was matched as c l o s e l y as p o s s i b l e . 5. Whether the p a t i e n t was h o s p i t a l i z e d - was matched i f p o s s i b l e . 6. M a r i t a l s t a t u s and o c c u p a t i o n a l s t a t u s were a l s o matched up as f a r as p o s s i b l e . U s i n g t h i s procedure 55 out of the 76 DCHC cases were matched e x a c t l y f o r sex, race and b i r t h p l a c e w i t h 55 out of the 75 cases t r e a t e d a t the WCC. When C h i Square t e s t s were performed on the 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 were o b s e r v a b l e between the groups i n terms of age, a r e a , a l c o h o l i c , o c c u p a t i o n a l and m a r i t a l s t a t u s , whether the p a t i e n t was h o s p i t a l i z e d or not and d i a g n o s e s of p a t i e n t s . T h i s procedure r e s u l t e d i n matching of 73% of the DCHC c a s e s . T h i s s t r a t i f i e d matching p r o c e s s r e s u l t e d i n a s e r i e s of non-normal d i s t r i b u t i o n s so t h a t a non-parametric s t a t i s t i c a l t e s t 63 was most a p p r o p r i a t e . A Wilcoxon Signed Rank Test was performed 25 to t e s t f o r a d i f f e r e n c e i n compliance between the matched p a i r s . A p a i r - w i s e match w i t h the c r i t e r i a o u t l i n e d was not a c h i e v a b l e f o r 21 cases a t the DCHC. These cases were t h e r e f o r e l e f t out of the t e s t i n g p r o c e s s . However, they were a n a l y z e d t o determine the e f f e c t of the m i s s i n g cases on the e v a l u a t i v e t e s t outcome. (See Chapter 8 S e c t i o n 8.1) 2. Question 2. What c h a r a c t e r i s t i c s or 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 best p r e d i c t compliance t o drug therapy a t the DCHC? A s t a t i s t i c a l model t o handle t h i s problem was d i f f i c u l t t o f i n d because the independent v a r i a b l e s are m a i n l y i n nominal form w h i l e compliance i s i n o r d i n a l form. By c o n s i d e r i n g the o r d i n a l s c a l e an i n t e r v a l 1 s c a l e , ANOVA t e c h n i q u e s can be used. In p a r t i c u l a r , M u l t i p l e 35 C l a s s i f i c a t i o n A n a l y s i s (MCA) was choosen because of the beta s t a t i s t i c i t produces which approximate t o a r e g r e s s i o n 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 of s t r e n g t h of a s s o c i a t i o n between independent and dependent v a r i a b l e s , MCA a l s o p r e s e n t s r e s u l t s i n terms of the amount of v a r i a t i o n from the dependent v a r i a b l e mean caused by each c a t e g o r y i n each independent v a r i a b l e . T h i s 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 of the data than would be a c c o m p l i s h e d u s i n g ANOVA a l o n e . A l s o , MCA can t e l l how much a second v a r i a b l e adds to the p r e d i c t a b i l i t y of the f i r s t v a r i a b l e . F i n a l l y , the e f f e c t s of the model as a whole can be a s c e r t a i n e d . 64 3. Q u e s t i o n 3. Who b e n e f i t s and who doesn't b e n e f i t from treatment a t the DCHC? T h i s q u e s t i o n was best answered by d i v i d i n g the compliance s c o r e s of a l l 76 cases a t the DCHC i n t o q u a r t i l e s . When the 76 cases were broken down i n t o q u a r t i l e s , compliance s c o r e s from 0 through 64% r e p r e s e n t e d the f i r s t q u a r t i l e , 65-92% the second q u a r t i l e , 93-99% the t h i r d q u a r t i l e and 100% the f o u r t h q u a r t i l e . C r o s s t a b u l a t i o n s were run f o r independent v a r i a b l e s i n r e l a t i o n t o these q u a r t i l e s f o r c o m p l i a n c e . From these c r o s s t a b u l a t i o n s a socio-demographic and treatment p r o f i l e was b u i l t up f o r the low t o h i g h compliance q u a r t i l e s t o i d e n t i f y who b e n e f i t s and who does not b e n e f i t from the DCHC program. In t h i s a n a l y s i s , p a r t i c u l a r a t t e n t i o n i s p a i d t o the r o l e of those independent v a r i a b l e s i d e n t i f i e d as p r e d i c t i v e of compliance i n the p r e v i o u s s e c t i o n . 4 . S e c t i o n 4 . C h a r a c t e r i z a t i o n of 'drop-outs' a t the DCHC. In t h i s t h e s i s attendance t o appointments has been the major dependent v a r i a b l e . While t h i s i s a f a i r l y e a s i l y measured v a r i a b l e , 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 i n f o r m a t i o n on f a i l u r e or success of treatment as opposed t o at t e n d a n c e . For example, a p a t i e n t who a c h i e v e d 100% compliance but dropped out of the c l i n i c a f t e r 8 weeks may have l e s s treatment s u c c e s s than a person who a t t e n d e d 65% of h i s / h e r appointments over a 45 week p e r i o d . Or, a person c o u l d be 100% c o m p l i a n t but drop out of the program a f t e r 6 weeks. A l t h o u g h such a case would 65 be r e g i s t e r e d as 100% c o m p l i a n t he/she may be a treatment f a i l u r e . Measuring attendance compliance o n l y does not t e l l us how many drop-outs occur i n the program or who the drop-outs a r e . To round out the e v a l u a t i o n of the DCHC, some assessment of the drop-out r a t e i s needed. To i d e n t i f y d r o p - o u t s , those p a t i e n t s who a t t e n d e d the DCHC f o r 6 months or l e s s were i d e n t i f i e d . Because many member of t h i s group had been h o s p i t a l i z e d 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 t r e a t m e n t , they were expected t o a t t e n d the DCHC f o r v a r y i n g p e r i o d s l e s s than 6 months. When t h i s group was s e p a r t e d out from the r e s t , the r e a l drop-outs were i s o l a t e d and d e s c r i b e d . 66 CHAPTER 8. THE EFFECT OF TWO TYPES OF CLINIC SYSTEMS ON COMPLIANCE TO TUBERCULOSIS CHEMOTHERAPY. RESULTS AND DISCUSSION The reader i s reminded t h a t the 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 best promotes c o m p l i a n c e ? ; 2) What f a c t o r s best p r e d i c t compliance a t the DCHC?; and 3) Who b e n e f i t s and who doesn't b e n e f i t from treatment a t the DCHC? 8.1 QUESTION 1: which c l i n i c best promotes compliance? The r e s u l t s of the Wilco x o n M a t c h e d - P a i r s Signed-Ranks Test u s i n g compliance w i t h appointments as dependent v a r i a b l e i n Table XI . TABLE X I : Wilcoxon M a t c h e d - P a i r s Signed-Ranks T e s t . Mean Rank Cases 12.00 3 -Ranks (DCHC l e s s than WCC) 28.41 51 +Ranks (DCHC g r e a t e r than WCC) 1 T i e s (DCHC eq u a l t o WCC) 55 TOTAL Z = -6. 0831 2-TAILED P= .0000 The W i l c o x o n Test t e s t s f o r s i g n i f i c a n t d i f f e r e n c e s i n compliance between each p a i r of matched c a s e s . The t e s t shows t h a t we must r e j e c t the n u l l h y p o t h e s i s t h a t compliance i n the two c l i n i c s i s equal a t p=0.000 l e v e l . The mean compliance f o r the 55 cases a t the WCC was 37% compared t o 83% f o r matched cases a t the DCHC. These r e s u l t s i n d i c a t e t h a t compliance i s s i g n i f i c a n t l y b e t t e r a t the DCHC. I t must be remebered t h a t t h i s r e s u l t i s v a l i d f o r the 55 67 matched c a s e s . What about the 21 unmatched cases? These cases were not matcheable because of the age d i s p a r i t y between the e x p e r i m e n t a l and c o n t r o l time p e r i o d s . ( T a b l e X I I ) TABLE X I I : Mean Ages In C o n t r o l and E x p e r i m e n t a l and Unmatched Groups By Race: Race 1977-79 1981-83 unmatched 1981-83 White 59.0 55.7 49.2 Nat i v e 49.3 44.7 44.8 Chinese 63.8 56.0 The mean ages f o r White and N a t i v e t u b e r c u l a r p a t i e n t s r e g i s t e r e d i n the Study Area dropped by a p p r o x i m a t e l y 5 y e a r s over the two time p e r i o d s . For Chinese the decrease was about 7 y e a r s . The decrease i n the mean age f o r Chinese cases may be e x p l a i n a b l e because of the i n f l u x of Vietnamese r e f u g e e s . These r e c e n t a r r i v a l s added a y o u t h f u l component t o the Chinese T.B. p o p u l a t i o n i n the a r e a . Because most of these younger Chinese p a t i e n t s were t r e a t e d a t the WCC d u r i n g the 1981-83 p e r i o d , matching was not an i s s u e f o r t h i s group. However, f o r 10 N a t i v e and 11 White cases t r e a t e d at the DCHC between 1981-83, age matches were s i m p l y not a v a i l a b l e i n the WCC C o n t r o l group t r e a t e d d u r i n g 1977-79. T h i s r e l a t i v e l y l a r g e downward a g e - s h i f t w i t h i n the Study Area over a 6 year span i s c u r i o u s and may be cause f o r concern and f u r t h e r study. ( T h i s s h i f t 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 because the c o h o r t 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 of t h i s g r o u p ) . How does the e x c l u s i o n of these 21 younger unmatched cases e f f e c t the comparison of compliance between the two c l i n i c s ? As i s shown i n S e c t i o n 8.2, younger p a t i e n t s tend t o be l e s s 68 c o m p l i a n t at the DCHC. Thus, the matching p r o c e s s has ex c l u d e d cases which are l i k e l y among the most non-compliant group. Our r e s u l t showing b e t t e r compliance a t the DCHC v e r s u s the WCC must be q u a l i f i e d by s t a t i n g t h a t compliance a t the DCHC was b e t t e r than a t the WCC f o r 73% of DCHC c a s e s . For the 27% of DCHC cases which were g e n e r a l l y younger p a t i e n t s , no c o n c l u s i o n s on r e l a t i v e c l i n i c e f f i c a c y i n terms of compliance can be drawn. Other m e d i c a l v a r i a b l e s f o r these matched groups can be examined t o a s s e s s the o v e r a l l impact of the DCHC on t u b e r c u l o s i s t r e a tment of the matched group. Table X I I I compares the e f f e c t of c l i n i c type on l e n g t h of treatment f o r those p a t i e n t s h o s p i t a l i z e d p r i o r t o o u t - p a t i e n t t r e a t m e n t . ( T h i r t y - f i v e cases were 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 t r e a t m e n t ) TABLE X I I I : T o t a l Length of T.B. Treatment f o r H o s p i t a l i z e d Cases CLINIC Len. of Hosp. (weeks) I n t e r v a l between d i s c h . and o.p. Len. of o.p. tre a t m e n t . T o t a l Len 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 c l i n i c s t r e a tment l e n g t h s were d i f f e r e n t . Matched h o s p i t a l i z e d p a t i e n t s t r e a t e d a t the WCC spent 14.4 weeks more than DCHC p a t i e n t s i n t r e a t m e n t . A p p r o x i m a t e l y h a l f t h i s d i f f e r e n c e i s accounted f o r by the l o n g e r h o s p i t a l s t a y s of WCC p a t i e n t s . ( I t i s e s s e n t i a l t o remember t h a t the expected l e n g t h of t r e a t m e n t a t the WCC o u t - p a t i e n t c l i n i c program between 1977-79 was 12-24 months so t h a t we would expect the l e n g t h of out-p a t i e n t treatment a t the WCC to be s i g n i f i c a n t l y g r e a t e r than f o r 69 the DCHC.) I t i s a l s o u s e f u l t o compare the e x p e r i e n c e of 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 the two c l i n i c s (Table X I V ) . TABLE XIV:Comparison 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 Cases. V a r i a b l e WCC DCHC H o s p i t a l i z e d Not hosp. H o s p i t a l i z e d Not hosp. Length of o u t - p a t . treatment (weeks) 43. 1 58.8 37.2 40.6 Complian. ( p e r c e n t ) 29.2 51 .8 82.8 88.3 Table XIV shows t h a t the e x p e r i e n c e of h o s p i t a l .ize d and non h o s p i t a l i z e d p a t i e n t s w i t h i n both c l i n i c s i s q u i t e d i f f e r e n t i n terms of l e n g t h of o u t - p a t i e n t 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 remain on o u t - p a t i e n t treatment f o r l e s s time and comply l e s s t o treatment than n o n - h o s p i t a l i z e d p a t i e n t s . T h i s i s l i k e l y e x p l a i n a b l e because of the s e l e c t i o n procedure s l o t t i n g those p a t i e n t s p e r c e i v e d as non-complianct i n t o the h o s p i t a l i z e d p o p u l a t i o n and those p a t i e n t s p e r c e i v e d as c o m p l i a n t i n t o the n o n - h o s p i t a l i z e d p o p u l a t i o n . In summary, t h e r e i s c l e a r l y a s i g n i f i c a n t d i f f e r e n c e between the WCC and DCHC i n terms of compliance t o o u t - p a t i e n t treatment f o r our matched groups. The DCHC shows an almost 50% b e t t e r compliance r e c o r d than the WCC. A.ls.*«, the f a c t t h a t , c l i n i c i a n s tend t o h o s p i t a l i z e p a t i e n t s p e r c e i v e d as non-compliant i s r e f l e c t e d i n the compliance s t a t i s t i c s computed a t both c l i n i c s . W h i l e l e n g t h of o u t - p a t i e n t treatment i s not s t r i c t l y 70 comparable a t the two c l i n i c s (because e x p e c t a t i o n s of treatment l e n g t h were d i f f e r e n t a t the two c l i n i c s ) i t i s c l e a r t h a t the t o t a l l e n g t h of treatment at the DCHC f o r the y e a r s 1981-83 was much l e s s than the t o t a l treatment l e n g t h a t the WCC f o r the y e a r s 1977-79. Given t h i s f a c t o r a l o n e , i t i s l i k e l y t h a t the e v o l u t i o n of the DCHC ( f o r d i f f i c u l t - t o - t r e a t p a t i e n t s ) i s not o n l y a p r o g r e s s i v e one i n terms of e f f i c a c y of treatment but i s a l s o p r o g r e s s i v e i n f i s c a l terms. 8.2 Q u e s t i o n 2: What f a c t o r s best p r e d i c t c ompliance a t the DCHC? A c c o r d i n g t o Chapter 6, socio-demographic and treatment f a c t o r s l i k e l y a f f e c t c o m p l i a n c e . The l i t e r a t u r e i s somewhat i n c o n c l u s i v e as t o the n a t u r e or the s t r e n g t h of the e f f e c t s of socio-demographic or treatment v a r i a b l e s on c o m p l i a n c e , p a r t i c u l a r l y as the l i t e r a t u r e on compliance among a g e n e r a l l y a l c o h o l i c a l i e n a t e d p o p u l a t i o n i s n e g l i g a b l e . To determine which v a r i a b l e s may a f f e c t compliance a One-Way A n a l y s i s of V a r i a n c e was done f o r each socio-demographic and treatment v a r i a b l e measured i n the s t u d y . These a n a l y s e s were performed on the 76 cases w i t h i n the study area d u r i n g the p e r i o d 81-83 who a t t e n d e d the DCHC. Socio-demographic v a r i a b l e s s i g n i f i c a n t l y a f f e c t i n g compliance at a p l e v e l of l e s s than .05 were age, a r e a , a l c o h o l i s m , o c c u p a t i o n and r a c e , i n t h a t o r d e r . The m e d i c a l v a r i a b l e s , d i a g n o s i s and whether 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 l e s s than 0.1. The e f f e c t of sex on compliance i s p r o b a b l y not r e l i a b l y measured because the number of females i s ten which i s about 12% of our sample. 71 TABLE XV: Oneway A n a l y s i s of V a r i a n c e f o r 12 Independent V a r i a b l e s i n R e l a t i o n t o the Dependent V a r i a b l e - Compliance. Independent V a r i a b l e F Value F - R a t i o Prob. Socio-demographic: AGE 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 STATUS 1 .8 0.1684 SEX 0. 1 0.6985 M e d i c a l : HOSPITALIZED? 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 -LENGTH OF O.P. TREAT 0.3 0.8265 Based on r e s u l t s i n s e c t i o n 8.1 and the s e l e c t i o n b i a s l i n k i n g h o s p i t a l i z a t i o n w i t h p e r c e i v e d non-compliance i t i s expected t h a t 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 have an impact on compliance. To more c l o s e l y a n a l y z e the e f f e c t of these v a r i a b l e s on the dependent 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 performed w i t h the seven v a r i a b l e s found s i g n i f i c a n t l y a f f e c t i n g c o mpliance. The...results a re p r e s e n t e d i n Table XVI. 72 TABLE XVI:MCA of 7 v a r i a b l e s i n r e l a t i o n t o Compliance. V a r i a b l e Unadjusted Eta A d j u s t e d f o r Independents Beta Area .39 .38 Age .39 .29 D i a g n o s i s .21 .26 Race .28 .20 H o s p i t a l i z e .19 .15 A l c o h o l i s m .10 .13 O c c u p a t i o n .20 .09 The beta s t a t i s t i c i s a s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t i n the sense used' i n m u l t i p l e r e g r e s s i o n . Beta i s a s s o c i a t e d w i t h the a d j u s t e d c a t e g o r y e f f e c t s f o r each v a r i a b l e . The e t a s t a t i s t i c i s a c o r r e l a t i o n r a t i o a s s o c i a t e d w i t h the u n a d j u s t e d c a t e g o r y e f f e c t s f o r each v a r i a b l e . By v i e w i n g the e t a s t a t i s t i c f o r each v a r i a b l e the c o r r e l a t i o n between a r e a and compliance i s s t r o n g e s t w i t h t h a t between o c c u p a t i o n and compliance weakest. When the e t a s t a t i s t i c i s a d j u s t e d f o r the e f f e c t s of the oth e r nominal v a r i a b l e s , 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 area remain r e l a t i v e l y u n a f f e c t e d by the o t h e r v a r i a b l e s . However, the e f f e c t s of race and age on the dependent v a r i a b l e i s reduced by about one t h i r d and the e f f e c t of o c c u p a t i o n by about a h a l f . What do the s e r e s u l t s mean? T a k i n g the model as a whole, a r e a , age, d i a g n o s i s and race ( i n t h a t o r d e r ) appear t o be the most p r e d i c t i v e of comp l i a n c e . W h i l e Table XVI shows these f o u r v a r i a b l e s may be the most p r e d i c t i v e f o r compliance the d i r e c t i o n of p r e d i c t i o n i s not shown. T h i s i s shown i n Ta b l e X V I I . 73 TABLE X V I I : MCA Table Showing D e v i a t i o n s from the Grand Mean=79 V a r i a b l e +Category N Unad j. Dev. Ad j . f o r Ind. Dev. AREA Area 1 (Core) 22 9.2 8.5 Area 2 (Outer Core) 23 2.36 3.1 Area 3 (Wings) 10 -11.7 -12.2 Area 4 ( F a r t h e s t ) 7 -19.9 -19.7 AGE 1-41 17 -14.0 -6.5 42-50 8 -4.2 -5.8 51-59 16 2.8 -2. 1 60-67 12 12.3 13.5 68-98 9 8.8 3.3 DIAGNOSIS Far Adv. 23 3.1 5.4 Mod. Adv. 22 -1.2 0.2 M i n i m a l 12 3.2 -2.5 Other 5 -17.0 -19.7 RACE Nat i v e 21 -8.2 -3.7 White 37 2.5 0.1 Chinese 4 19.8 18.6 HOSPITALIZED? Yes 47 -2.8 -2. 1 No 15 8.8 6.7 ALCOHOLISM Yes 49 -1 .3 1 .8 No 1 3 4.8 -6.6 OCCUPATION Employed 12 10.1 -3.3 Unemployed 44 -2.8 0.2 R e t i r e d 6 0.3 5.2 Table XVII shows t h a t f o r the 76 cases at the DCHC, used i n t h i s a n a l y s i s , the compliance mean (grand mean) was 79%. The un a d j u s t e d d e v i a t i o n column shows the d e v i a t i o n from the grand mean produced by each f a c t o r w i t h i n c a t e g o r i e s . The a d j u s t e d d e v i a t i o n shows the e f f e c t of each f a c t o r a f t e r a l l o t h e r f a c t o r s a re c o n t r o l l e d f o r . Ta b l e XVII appears t o c o n f i r m the r e s u l t s of S e c t i o n 8.1 i n terms of h o s p i t a l i z a t i o n . I t i s somewhat s u r p r i s i n g t h a t the impact 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 s m a l l r e l a t i v e t o 74 the o t h e r 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 i s a s e l e c t i o n v a r i a b l e f o r p e r c e i v e d compliance. In terms of d i a g n o s i s , t h e r e i s a f a i r l y c o n s i s t e n t r e l a t i o n s h i p between s e v e r i t y of d i s e a s e and co m p l i a n c e . As d i s e a s e s e v e r i t y i n c r e a s e s so does the p o s i t i v e d e v i a t i o n from the compliance mean. Area a l s o shows a c o n s i s t e n t r e l a t i o n s h i p w i t h c o m p l i a n c e . P o s i t i v e d e v i a t i o n s from the compliance mean i n c r e a s e 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 the c l i n i c . Race shows the same constancy w i t h N a t i v e s h a v i n g a n e g a t i v e d e v i a t i o n from the mean, Whites b e i n g a t the mean and Chinese h a v i n g a l a r g e p o s i t i v e d e v i a t i o n from the mean. P a t i e n t c a t e g o r i e s over 60 y e a r s of age had a p o s i t i v e d e v i a t i o n from the mean. Those under 60 had n e g a t i v e d e v i a t i o n from the mean. For the under 60 c a t e g o r i e s t h e r e was a r e g u l a r i n c r e a s i n g n e g a t i v e d e v i a t i o n from the mean goi n g 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 compliance i s shown i n Table XVI11. TABLE X V I I I : Mean Compliance f o r Recoded Age C a t e g o r i e s . AGE CATEGORY MEAN COMPLIANCE (%) 1 t o 41 63.3 42 t o 50 72. 1 51 t o 59 83.7 60 t o 67 90.0 over 68 98.9 The r e s u l t s f o r the v a r i a b l e a l c o h o l i s m are i n t e r e s t i n g . I t appears t h a t a l c o h o l i s m i s not c o r r e l a t e d w i t h c o m p l i a n c e . R e s u l t s i n d i c a t e t h a t when a d j u s t e d f o r o t h e r v a r i a b l e s i n the 75 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 . T h i s r e s u l t has a d i r e c t b e a r i n g on the c l i n i c because one of the major s e l e c t i o n c r i t e r i a i n t o the DCHC i s a l c o h o l i s m . In oth e r words, 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 i s a major i n d i c a t o r of p o t e n t i a l non-compliance. The l i m i t e d r e s u l t s here show t h a t a l c o h o l i s m may be a ve r y minor f a c t o r compared t o age, area and r a c e . In summary, area of r e s i d e n c e i n r e l a t i o n t o the c l i n i c i s the s t r o n g e s t p r e d i c t o r of compliance f o l l o w e d by age and d i a g n o s i s . Race, h o s p i t a l i z a t i o n , a l c o h o l i s m and o c c u p a t i o n are weaker p r e d i c t o r s f o r c o m p l i a n c e . A more d e t a i l e d e x p l o r a t i o n of these r e l a t i o n s h i p s are p r e s e n t e d i n the next s e c t i o n . 8.3 QUESTION 3: Who b e n e f i t s and who doesn't b e n e f i t from treatment a t the DCHC? In t h i s s e c t i o n the 76 cases at the DCHC were d i v i d e d i n t o q u a r t i l e s i n terms of t h e i r compliance and a s e r i e s of c r o s s t a b u l a t i o n s and breakdowns run t o develop a p r o f i l e of socio-demographic and treatment c h a r a c t e r i s t i c s f o r a l l 4 groups u s i n g the 5 major p r e d i c t i v e v a r i a b l e s : a r e a , age, r a c e , d i a g n o s i s and h o s p i t a l i z a t i o n . When the 76 cases were broken down i n t o q u a r t i l e s , compliance s c o r e s from 0 though 64% r e p r e s e n t e d the f i r s t q u a r t i l e , 65-92% the second q u a r t i l e , 93-99% the second q u a r t i l e , and 100% the f o u r t h q u a r t i l e . 76 1.Socio-demographic V a r i a b l e s : A)AGE. TABLE XIX: C r o s s t a b , of Age Category by Compliance 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 each age c a t e g o r y ) Quart i l e 1 -41 42-50 A G E 51-59 60-67 68-98 1 low 2 3 4 h i g h 9 (45) 8 (40) 2 (10) 1 (5) 4 (34) 1 (8) 4 (33) 3 (25) 4 (20) 3 (15) 6 (30) 7 (35) 1 (8) 6 (46) 3 (23) 3 (23) 1 (10) 0 1 (10) 8 (80) The mean age of the h i g h compliance q u a r t i l e was 62.7 y e a r s . For the low compliance q u a r t i l e the mean age was 42.3 y e a r s a d i f f e r e n c e of a p p r o x i m a t e l y 20 y e a r s . In terms of c o m p l i a n c e , 85% of the youngest age group (1-41) a r e below the 50 p e r c e n t i l e compared to 10% w i t h i n the o l d e s t age group (68-98). C o n v e r s e l y , 15% of the youngest age c a t e g o r y i s above the 50 p e r c e n t i l e compared t o 90% w i t h i n the o l d e s t age c a t e g o r y . B)AREA. TABLE XX: C r o s s t a b of Area by Compliance 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.) Q u a r t i l e Area 1 Area 2 Area 3 Area 4 (Core) (Outer-Core) (Wings) ( F a r t h e s t ) 1 low 4 (17) 7 (23) 4 (33) 5 (50) 2 3 (13) 8 (26) 6 (50) 1 (10) 3 4 (17) 9 (29) 2 (17) 1 (10) 4 h i g h 12 (53) 7 (23) 0 3 (30) A p p r o x i m a t e l y 70% of the c o r e a r e a r e s i d e n t s a re above the 50 p e r c e n t i l e f o r compliance compared t o 40% of the f a r t h e s t and 17% of the wing area r e s i d e n t s . A p p r o x i m a t e l y 86% of the h i g h compliance group l i v e s i n the c o r e or o u t e r - c o r e are;-"compared t o 53% of the low compl i a n c e group. Because i t i s known t h a t the c o r e area has a number of government hou s i n g u n i t s s p e c i f i c a l l y geared t o s e n i o r r e s i d e n t s 77 an e x p l o r a t i o n of the l i n k between age and area was ne c e s s a r y . In f a c t , the mean age i n the co r e area i s 61.1 yea r s , and 49.0 y e a r s f o r the o u t e r - c o r e a r e a , 45.5 yea r s f o r the wing areas and 50.0 f o r the f a r t h e s t a r e a . Thus, the core area c o n t a i n s a p o p u l a t i o n w i t h a mean age at l e a s t a decade g r e a t e r than f o r the othe r a r e a s . T h i s makes i t v e r y d i f f i c u l t t o determine whether the c o r e a r e a group i s more c o m p l i a n t because i t i s l o c a t e d c l o s e r t o the c l i n i c or because i t i s an o l d e r and t h e r e f o r e a more c o m p l i a n t group. To see i f age and area i n t e r a c t t o e f f e c t compliance a 2-Way A n a l y s i s of V a r i a n c e was performed on the 76 DCHC cases u s i n g age and a r e a as independent v a r i a b l e s . ( T a b l e X X I ) C l e a r l y , t h e r e i s l i t t l e i n t e r a c t i o n between age and area i n d e t e r m i n i n g compliance. T h e r e f o r e , area e f f e c t s compliance i n d e p e n d e n t l y of age. TABLE XXI: ANOVA f o r Age and Area w i t h Compliance Source of V a r i a t i o n F-Value S i g n i f i c a n c e of F Main E f f e c t s 3.0 .009 Age 2.3 .070 Area 2.0 .122 2-Way I n t e r a c t i o n 1.2 .301 C)RACE. TABLE X X I I : C r o s s t a b of Race by Compliance 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 each race c a t e g o r y ) A p p r o x i m a t e l y 72% of Chinese p a t i e n t s a t the DCHC are i n the 78 h i g h compliance q u a r t i l e compared t o 60% of w h i t e s and 25% of n a t i v e s . C o n v e r s e l y , 76% of n a t i v e s a t the c l i n i c are below the 50 p e r c e n t i l e of compliance compared t o 38% f o r w h i t e s and 28% f o r C h i n e s e . These r e s u l t s i n d i c a t e a s i g n i f i c a n t r e l a t i o n s h i p between race and c o m p l i a n c e . T h i s r e s u l t must be i n t e r p r e t e d c a r e f u l l y as i t was shown i n the p r e v i o u s s e c t i o n t h a t e f f e c t s of the v a r i a b l e race were reduced by about one t h i r d when o t h e r independent v a r i a b l e s were added t o the model. When we review the age s t r u c t u r e of the major r a c i a l groups u s i n g the c l i n i c we f i n d the mean age f o r Chinese was 65.2 y e a r s , f o r Whites 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 . To determine whether t h e r e i s i n t e r a c t i o n between race and age a 2-Way ANOVA was performed. R e s u l t s were the same as those f o r age and a r e a , t h a t i s no i n t e r a c t i o n e f f e c t between age and r a c e . The p a t t e r n of h o s p i t a l i z a t i o n a l s o i n t e r a c t s w i t h r a c e , ( T a b l e XXI11 ) TABLE X X I I I : H o s p i t a l i z a t i o n by Race. H o s p i t a l i z a t i o n ? RACE Chinese | N a t i v e White H o s p i t a l i z e d 5 19 29 Not h o s p i t a l i z e d 2 4 1 3 h o s p i t a l i z e d compared t o n o n - h o s p i t a l i z e d . However w i t h i n the N a t i v e c a t e g o r y 6 times as many n a t i v e s a re h o s p i t a l i z e d as compared t o n o n - h o s p i t a l i z e d . The l i k l i h o o d of a n a t i v e b e i n g h o s p i t a l i z e d i s t h e r e f o r e much g r e a t e r than f o r the o t h e r r a c e s . N a t i v e s a re p r o b a b l y p e r c e i v e d as non-compliant by the c l i n i c i a n s 79 at 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 V a r i a b l e s : A)DIAGNOSIS. TABLE XX I V : D i a g n o s i s by Compliance Q u a r t i l e . Q u a r t i l e Far Adv. Mod Adv. M i n i m a l Other 1 low 5 (20) 8- (30) 3 (19) 4 (57) 2 5 (20) 6 (22) 4 (25) 2 (29) 3 4 (16) 10(37) 1 (6) 1 (14) 4 h i g h 11 (44) 3 ( 1 1 ) 8 (50) F o r t y f o u r p e r c e n t of f a r advanced cases a r e i n the h i g h compliance q u a r t i l e compared w i t h 11% of moderately advanced cases and 50% of minimal c a s e s . While no r e a l p a t t e r n i s d i s c e r n a b l e , i t i s c l e a r t h a t 74% of the cases above the 50 p e r c e n t i l e f o r compliance are e i t h e r diagnosed as moderately advanced or f a r advanced. A c c o r d i n g t o the a n a l y s i s i n the p r e v i o u s s e c t i o n d i a g n o s i s a c t s i n d e p e n d e n t l y of o t h e r independent v a r i a b l e s . 1 B)HOSPITALIZED? TABLE X X V : H o s p i t a l i z a t i o n by Compliance Q u a r t i l e Q u a r t i l e | H o s p i t a l i z e d |~ N o t - h o s p i t a l i z e d 1 low 16 (30) 2 (11) 2 14 (27) 3 ( 1 7 ) 3 10 (19) 6 (33) 4 h i g h 13 (25) 7 (39) F i f t y t h r e e cases were h o s p i t a l i z e d , e i g h t e e n were not h o s p i t a l i z e d and the f a t e of f i v e cases was unknown. From Table XXV the p r o p o r t i o n of n o n - h o s p i t a l i z e d cases above the 50 p e r c e n t i l e f o r compliance i s almost double the p r o p o r t i o n of h o s p i t a l i z e d c a s e s . In summary, ( i n terms of socio-demographic v a r i a b l e s ) o l d e r 80 t u b e r c u l o s i s and who have not been h o s p i t a l i z e d t e n d t o p e r f o r m bes t as o u t - p a t i e n t s i n terms of a t t e n d a n c e c o m p l i a n c e C o n v e r s e l y , younger p a t i e n t s ( the se a r e u s u a l l y Whi te and N a t i v e i n e q u a l p r o p o r t i o n ) who have l e s s s evere d i a g n o s i s , l i v e f a r t h e r from the c l i n i c and who have been h o s p i t a l i z e d t e n d t o p e r f o r m w o r s t as o u t - p a t i e n t s i n terms of a t t e n d a n c e c o m p l i a n c e . What do these f i n d i n g s mean i n terms of the T . B e p i d e m i o l o g y of t h e Study Area? I t was shown i n C h a p t e r 5 t h a t the age group 20-59 had a d i s p r o p o r t i o n a t e number of c a se s compared t o the p o p u l a t i o n of the Study A r e a . The f i n d i n g s i n t h i s c h a p t e r a l s o i n d i c a t e t h a t t h i s age group i s among the l e a s t c o m p l i a n t t o t r e a t m e n t . O b v i o u s l y , t h i s group w h i c h i s m a i n l y W h i t e or N a t i v e C a n a d i a n - b o r n must r e c e i v e s p e c i a l a t t e n t i o n from the DCHC. F i n d i n g s f o r t h i s c h a p t e r a l s o suggest t h a t N a t i v e s a r e h o s p i t a l i z e d f a r more f r e q u e n t l y than o t h e r groups even though s e v e r i t y of d i a g n o s i s a p p e a r s ' n o g r e a t e r f o r N a t i v e s . N a t i v e s s t i l l appear o v e r - r e p r e s e n t e d i n the low c o m p l i a n c e q u a r t i l e . T h i s may suggest t h a t the 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 the N a t i v e group may not 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 DCHC. 8.4 DROP-OUTS: Of 76 DCHC c a s e s , 16 a t t e n d e d f o r l e s s than 6 months . Of the group w h i c h had l e s s than 6 months t r e a t m e n t as o u t - p a t i e n t s a p r o p o r t i o n cannot be c o n s i d e r e d d r o p - o u t s because t h e y needed s h o r t e r t r e a t m e n t a t the DCHC as they r e c e i v e d much of t h e i r c a r e as i n - p a t i e n t s . In f a c t 5 of the 16 ca se s a t t e n d i n g the DCHC f o r l e s s than 6 months r e c e i v e d an average of 45 weeks of u n i n t e r r u p t e d chemotherapy because of t h e i r i n - p a t i e n t c a r e . T h i s 82 l e f t 9 out of 76 cases who c o u l d be c o n s i d e r e d d r o p - o u t s . 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 t o t r y and determine whether they were t r u e non-compling d r o p - o u t s . In f a c t , f i v e of the nine cases moved t o o t h e r c i t i e s i n B.C. A f o l l o w - u p of these f i v e r e c o r d s showed they a l l completed a c o u r s e of out -p a t i e n t chemotherapy a t another c l i n i c . T h i s l e f t f o ur cases who s t a y e d i n the ar e a and appeared t o be d r o p - o u t s . However, t h r e e of these f o u r cases were d i s c o n t i n u e d from the DCHC program by p h y s i c i a n s o r d e r . One of these was d i s c o n t i n u e d because she was such a 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 h e r s e l f a t home. Another was d i s c o n t i n u e d because he devel o p e d r e n a l f a i l u r e and c o u l d not t o l e r a t e the drugs. The t h i r d case was d i s c o n t i n u e d because he proved c o m p l e t e l y u n c o o p e r a t i v e . The s i n g l e t r u e drop-out was a 24 year o l d Vietnamese woman who r e c e i v e d 12 weeks of chemotherapy on the DCHC program and then d i s a p p e a r e d f o r 9 months. Thus, of the 9 apparent drop-outs 6 completed s u c c e s s f u l c o u r s e s of T.B. chemotherapy. Two cases were d i s c o n t i n u e d from the program by p h y s i c i a n o r d e r and were t h e r e f o r e not t r u e non-complying d r o p - o u t s . In c o n c l u s i o n , one out of 76 cases can be c a l l e d a drop-out. T h i s means the drop-out r a t e a t the DCHC f o r r e s i d e n t s of the Study Area d u r i n g the Study P e r i o d was about 1.5 p e r c e n t . 83 Whether a person was a l c o h o l i c or not, or employed or unemployed had l i t t l e e f f e c t on co m p l i a n c e . Residence i n r e l a t i o n t o the c l i n i c i s the s i n g l e most impo r t a n t p r e d i c t o r . I f we a n a l y z e the maximum d i s t a n c e of each of the f o u r recoded a r e a s from the DCHC i t i s e v i d e n t t h a t Area 1 l i e s w i t h i n a 0.5 k i l o m e t e r r a d i u s of the c l i n i c , Area 2 w i t h i n a 1 k i l o m e t e r 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 r a d i u s and Area 4 w i t h i n a 4 k i l o m e t e r r a d i u s of the c l i n i c . I t i s c l e a r from the data t h a t 70% of r e s i d e n t s w i t h i n 0.5 k i l o m e t e r s of the c l i n i c a t t e n d e d 93% of appointments or more (Area 1 ) . F i f t y - t w o p e r c e n t of r e s i d e n t s l o c a t e d between 0.5 and 1 k i l o m e t e r from the c l i n i c a t t e n d e d 93% of appointments or more (Area 2 ) . For d i s t a n c e s g r e a t e r than 1 k i l o m e t e r from the DCHC attendance t o 93% or more of appointments was a c h i e v e d by o n l y 30% of r e s i d e n t s . These data suggest t h a t f o r the skid-row p o p u l a t i o n under s t u d y , the most e f f e c t i v e l o c a t i o n f o r c l i n i c s e r v i c e s i s w i t h i n 1 k i l o m e t e r of c l i e n t s r e s i d e n c e s . An i n t e r e s t i n g f i n d i n g i n t h i s study was t h a t a l c o h o l i s m appears as a minor f a c t o r p r e d i c t i n g a t tendance c o m p l i a n c e . A l c o h o l i s m i s a major s e l e c t i o n f a c t o r used by p h y s i c i a n s a t the WCC f o r p l a c i n g p a t i e n t s i n the DCHC program. In view of the f i n d i n g s i n t h i s s t u d y , 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 the b a s i s of some of the o t h e r p r e d i c t i v e v a r i a b l e s p a r t i c u l a r l y age, race and a r e a . 3.The t h i r d q u e s t i o n : The answer t o t h i s q u e s t i o n f o l l o w s from the second q u e s t i o n . O l d e r persons who l i v e c l o s e t o the c l i n i c and have more severe d i a g n o s e s tend t o a t t e n d w e l l . I f the o l d e r person i s Chinese or 85 p a t i e n t s tend t o b e n e f i t most i n terms of compliance and younger c l i e n t s l e a s t . A l t h o u g h a socio-demographic g r a d i e n t of i n c r e a s i n g 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 the DCHC, p r o x i m i t y t o 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 i n terms of c o m p l i a n c e . L o c a t i o n i n r e l a t i o n to the c l i n i c i s the s i n g l e most p o t e n t socio-demographic v a r i a b l e e f f e c t i n g c o m p l i a n c e . Age, race and h o s p i t a l i z a t i o n are l i n k e d . Age may appear more s i g n i f i c a n t than i t r e a l l y i s because the t h r e e r a c i a l groups i n the a r e a have unique age s t r u c t u r e s . I t i s p a r t i c u l a r l y i n t e r e s t i n g t o note t h a t 86% of N a t i v e T.B. p a t i e n t s a r e h o s p i t a l i z e d compared t o r e s p e c t i v e l y 67% of White and 71% of Chinese p a t i e n t s . I t may be t h a t c l i n i c i a n s at the T.B. D i v i s i o n view n a t i v e s as more non-compliant and tend t o h o s p i t a l i z e them more f r e q u e n t l y than o t h e r r a c i a l groups. Another p o s s i b l i l i t y i s t h a t N a t i v e s t e n d t o p r e s e n t w i t h more severe diagnoses t h e r e b y r e q u i r i n g h o s p i t a l i z a t i o n . However, r e f e r e n c e to Table XXVI shows t h a t s e v e r i t y of d i a g n o s i s among N a t i v e s appears l e s s than among the White group. (63% of N a t i v e s have moderate or far-advanced d i a g n o s e s compared t o 80% of Whites) TABLE XXVI: C r o s s t a b u l a t i o n of Race and D i a g n o s i s . RACE Far-adv. Mod.-adv. M i n i m a l Other Nat i v e 6 (27%) 8 (36%) 3 (14%) 5 (23%) White 17 (41%) 16 (39%) 7 (17%) 1 (3%) Chinese 2 (29%) 1 (14%) 3 (42%) 1 (14%) In g e n e r a l , o l d e r White or Chinese p a t i e n t s who l i v e c l o s e t o the c l i n i c who have been diagnosed w i t h far-advanced or moderate 81 RECOMMENDATIONS To i n c r e a s e the e f f e c t i v e n e s s of the DCHC, T.B. D i v i s i o n s t a f f must know who i s at h i g h r i s k f o r non-compliance at the DCHC. That i s , Canadian-born younger p a t i e n t s ( p a r t i c u l a r l y those l i v i n g a t a d i s t a n c e from the c l i n i c ) must r e c e i v e s p e c i a l a t t e n t i o n . I t i s recommended t h a t the r o l e of the T.B. nurse at the c l i n i c be enhanced t o g i v e t h i s s p e c i a l a t t e n t i o n . S p e c i f i c a l l y , the T.B. nurse needs t o expand her r e g u l a r home-v i s i t r o u t e beyond c u r r e n t b o u n d a r i e s (which extend r o u g h l y between Abbot S t r e e t and H e a t l e y S t r e e t and H a s t i n g s and the w a t e r f r o n t ) . 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 c l i n i c c o n t a c t w i t h the young a t - r i s k group l i v i n g a t a d i s t a n c e from the DCHC. T h i s expanded r o l e has c u r r e n t urgency because of l o c a l Expo-86 r e l a t e d upheavals underway on s k i d - r o w . Because of the importance of r e s i d e n c e i n r e l a t i o n to the c l i n i c i n terms of a t t e n d a n c e c o m p l i a n c e , i t i s v e r y important t h a t p l a n n e r s l o c a t e o u t - p a t i e n t c l i n i c s e r v i c e s v e r y c l o s e l y to the main area of r e s i d e n c e f o r the t u b e r c u l a r skid-row p o p u l a t i o n . T h i s means t h a t any development of t u b e r c u l o s i s s e r v i c e s f o r t h i s p o p u l a t i o n must be based on a c c u r a t e address i n f o r m a t i o n . For s k i d - r o w a r e a s l i k e Vancouver's which are undergoing r a p i d change and p o p u l a t i o n f l u x , t u b e r c u l o s i s c o n t r o l p l a n n e r s may have t o e s t a b l i s h s a t e l l i t e c l i n i c s to e s s e n t i a l l y ' f o l l o w ' s k id-row p o p u l a t i o n s as they r e l o c a t e . 87 REFERENCES 1. Andrews, F.M., Klem, L., Davidson, T.N., O'Malley, P.M., Rodgers, 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  f o r A n a l y z i n g S o c i a l S c i e n c e Data. Ann A r b o r , M i c h i g a n , U n i v e r s i t y of M i c h i g a n , 1981. 2. Bahr, H.M., "The G r a d u a l Disappearance of Skid-Row." S o c i a l Problems ,15:41-45, 1967. 3. Bakan, R. , Report on the H e a l t h S t a t u s of Census T r a c t s 57, 58, and 59, C i t y of Vancouver H e a l t h and P l a n n i n g Departments, December, 1978. 4. B a r n e t t , G.D., G r z y b owski, S., S t y b l o , K., " P r e s e n t R i s k of D e v e l o p i n g 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 t o P r e v i o u s 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  the I n t e r n a t i o n a l Union f o r T u b e r c u l o s i s , 45:51-74, 1971. 5. Becker, 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 P r e d i c t o r s 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 R e p o r t s . 87:852-862, 1972. 6. Bogue, D.J., Skid-Row i n American C i t i e s . C h i c a g o, U n i v e r s i t y of Chicago P r e s s , 1963. 7. Canada, Royal Commission 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 i n Canada. Ottawa, 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 York, M e d i c a l L i f e P r e s s , 1933. 9. Chao, C.W., " P e r s o n a l Communication." May, 1985. 10. Chapman, J.S., D y e r l y , M.D. " S o c i a l and Other F a c t o r s i n the i n t e r - f a m i l i a l t r a n s m i s s i o n of t u b e r c u l o s i s . " American  Review of R e s p i r a t o r y D i s e a s e , 80:48, 1964. 11. Chaves, A.D., R o b i n s , A.B., A b e l e s , H. "T.B. Case F i n d i n g Among Homeless Men i n New York C i t y . "American Review of  R e s p i r a t o r y D i s e a s e . 87:102-104, 1961. 12. Comstock, G.W. P r e v e n t i v e M e d i c i n e and P u b l i c H e a l t h . New York, A p p l e t o n - C e n t u r y - C r o f t s , 1973. 13. Cooke, N.J. "Treatment of T u b e r c u l o s i s . " B r i t i s h M e d i c a l J o u r n a l ,291:497-498, 1985. 14. D a n i e l , T.M., " S e l e c t i v e Primary H e a l t h 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 the D e v e l o p i n g World, I I : T u b e r c u l o s i s . " R e v i e w s 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 of S e l f - A d m i n i s t e r e d 88 CHAPTER 9 CONCLUSIONS AND RECOMMENDATIONS. CONCLUSIONS. T h i s t h e s i s s e t out t o examine t h r e e q u e s t i o n s : 1) I s the communi ty-based o u t - p a t i e n t t r e a t m e n t sys tem a t t h e DCHC b e t t e r ( i n terms of a t t e n d a n c e c o m p l i a n c e ) than the h o s p i t a l - b a s e d sys tem a t the WCC f o r s k i d - r o w p a t i e n t s ? 2) Which s o c i o -demographic and t r e a t m e n t f a c t o r s p r e d i c t a t t e n d a n c e c o m p l i a n c e a t the DCHC? and ; 3) Who b e n e f i t s and who does not b e n e f i t from the new t r e a t m e n t s y s t e m . 1. The f i r s t q u e s t i o n : In terms of a t t e n d a n c e c o m p l i a n c e , the DCHC has s i g n i f i c a n t l y g r e a t e r a t t e n d a n c e t o o u t - p a t i e n t a p p o i n t m e n t s than the WCC when compar ing a matched p o p u l a t i o n 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 . The DCHC, w h i c h r e p r e s e n t s one of the l a t e s t deve lopment s i n t u b e r c u l o s i s t r e a t m e n t systems appear s t o promote b e t t e r a t t e n d a n c e 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 than the WCC. The communi ty-based approach a t the DCHC i s a s i g n i f i c a n t improvement over the former h o s p i t a l - b a s e d a p p r o a c h f o r s k i d - r o w p a t i e n t s . 2 . The second q u e s t i o n : A r e a , age , d i a g n o s i s and r a c e ( i n t h a t o r d e r ) a r e the main f a c t o r s p r e d i c t i n g a t t e n d a n c e c o m p l i a n c e a t the DCHC. P a t i e n t s who l i v e c l o s e s t t o the c l i n i c a t t e n d a p p o i n t m e n t s b e t t e r than those who l i v e f a r away. O l d e r p a t i e n t s a t t e n d b e t t e r than younger p a t i e n t s . P e r s o n s w i t h more s evere d i a g n o s e s a t t e n d b e t t e r than those w i t h l e s s s e v e r e d i a g n o s e s . In g e n e r a l , C h i n e s e a t t e n d b e t t e r than 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 than N a t i v e s . 84 Versus S u p e r v i s e d Treatment i n Sin g a p o r e . " B u l l e t i n of the I n t e r n a t i o n a l Union f o r T u b e r c u l o s i s , 4 7 : 1 5 - 2 1 , 1972. 16. Dubos, J . , Dubos, R.,The White Plague. Boston, L i t t l e Brown and Co., 1952. 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 With 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 Research C o u n c i l , " C o n t r o l l e d T r i a l s of Short-Course (6 month) Regimens of Chemotherapy f o r Treatment of Pulmonary T u b e r c u l o s i s . " Lancet ,1079-1085, 1972. 19. Enarson, D.A., S j o g r e n , I . , G r z y b o w s k i , S., " I n c i d e n c e of T u b e r c u l o s i s Among Scandanavian Immigrants i n Canada." European J o u r n a l of R e s p i r a t o r y D i s e a s e ,61:139-142, 1980. 20. Enarson, D.A., " A c t i v e T u b e r c u l o s i s i n Indo-Chinese Refugees i n B.C.."Canadian 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. Enarson, D.A., " P e r s o n a l Communication." An u n p u b l i s h e d r e p o r t on t u b e r c u l o s i s i n Vancouver, 1984. 22. Enarson, D.A., " P e r s o n a l Communication." F e b r u a r y , 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 Test R e a c t i o n Among A d u l t s 25-74 Y e a r s , U n i t e d S t a t e s , 1971-72. N a t i o n a l H e a l t h Survey, s e r i e s I I , no.204, P u b l i c a t i o n No. (HRA) 77-1649. U.S. Department of H e a l t h , E d u c a t i o n and W e l f a r e , Washington, D.C., 1977. 24. Fox, W., " Compliance of P a t i e n t s and 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 : I I . " B r i t i s h M e d i c a l  J o u r n a l ,287:101-105, 1983. 25. H o l l a n d e r , M., Wolfe, D.A., Nonparametric S t a t i s t i c a l Methods. New York, London, Sydney, To r o n t o , 1973. 26. H o r w i t z , 0., " T u b e r c u l o s i s R i s k and M a r i t a l S t a t u s . " American Review of 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 M e d i c a l Research C o u n c i l , " C o n t r o l l e d T r i a l of 6 and 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 , P l u s 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 Hong-Kong."Tubercule ,56:81-96, 1975. 28. Jang, K., "A C o m p a r i t i v e E v a l u a t i o n of H o s p i t a l V e r s u s C l i n i c E d u c a t i o n of T u b e r c u l o s i s P a t i e n t s i n Vancouver." U n p u b l i s h e d M a s ters T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1978. 89 White he/she w i l l more l i k e l y a t t e n d b e t t e r than a N a t i v e p e r s o n . Younger p a t i e n t s ( e s p e c i a l l y those who l i v e f a r from the c l i n i c ) dominate the ranks of the low compliance q u a r t i l e . These p a t i e n t s tend t o be White or N a t i v e i n about e q u a l p r o p o r t i o n . Another purpose t o the t h e s i s was t o gat h e r some e p i d e m i o l o g i c a l d ata on t u b e r c u l o s i s i n s k i d - r o w . T h i s study showed t h a t Study Area r a t e s were i n the r e g i o n of 250 per hundred thousand and r a t e s i n the Downtown-Eastside approached 375 per hundred thousand d u r i n g the Study P e r i o d . R e s u l t s i n d i c a t e t h a t 60% of cases i n the Study Area were Canadian-born. Of t h e s e , 40% were N a t i v e and 60% non-Native. 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 cases i n the a r e a . Rates i n the Study Area appear r e l a t i v e l y s t a b l e as does the mix of cases among the 3 h i g h - r i s k groups. However, the ar e a i s r a p i d l y d e p o p u l a t i n g due t o Expo-86 r e l a t e d developments so t h a t f a i r l y s t a b l e a b s o l u t e numbers may i n d i c a t e i n c r e a s i n g r a t e s i n the Study A r e a . S i x t y p e r c e n t of cases i n the area were Canadian-born. T h i s group r e p r e s e n t s the m a j o r i t y of cases i n the a r e a . Canadian-born persons a re a l s o more l i k e l y t o belong t o the ' d i f f i c u l t - t o -t r e a t ' group r e f e r r e d t o the DCHC. Once r e f e r r e d t o the DCHC Canadian-born persons a r e a t h i g h e s t r i s k f o r non-compliance t o appointments. Thus, the Canadian-born cases i n the Study Area r e q u i r e p a r t i c u l a r a t t e n t i o n i n terms of t u b e r c u l o s i s c o n t r o l . 86 29. Kuemmerer, J.M., Comstock, G.W., " S o c i o l o g i c a l Concomitants of T u b e r c u l i n S e n s i t i v i t y . " American Review of R e s p i r a t o r y  D i s e a s e , 96:885, 1967. 30. Moorman, L . J . , T u b e r c u l o s i s and Genius. Chicago, U n i v e r s i t y of Chicago P r e s s , 1940. 31. Ramsay, J . Community H e a l t h N u r s i n g i n Canada. Toronto, Gage P u b l i s h i n g Co., 1965. 32. Reichman, L.B., O'Day, R., " T u b e r c u l o s i s I n f e c t i o n i n a Large Urban P o p u l a t i o n . " American Review of R e s p i r a t o r y D i s e a s e , 117:705-712, 1978. 33. Rubbington, E., "The Changing Skid-Row Scene." Q u a r t e r l y J o u r n a l of S t u d i e s i n A l c o h o l i s m ,32:123-135, 1971. 34. Sbarbaro, J.A., Johnson, S. " T u b e r c u l o s i s Chemotherapy f o r R e c a l c i t r a n t O u t - P a t i e n t s A d m i n i s t e r e d D i r e c t l y Twice-Weekly." American Review of R e s p i r a t o r y D i s e a s e ,99:895-903, 1967. 35. SPSS X User's Guide: A Complete Guide t o SPSS X Language and O p e r a t i o n s . C h i c a go, M c G r a w - H i l l Book Company, 1983. 36. S t a t i s t i c s Canada:Annual Report on T u b e r c u l o s i s S t a t i s t i c s , M o r b i d i t y and M o r t a l i t y , 1963. Cat. 83-206, Queens P r i n t e r , Ottawa, 1965. 37. S t a t i s t i c s Canada:Annual Report on T u b e r c u l o s i s S t a t i s t i c s , M o r b i d i t y and M o r t a l i t y , 1964. Cat. 83-206, Queens P r i n t e r , Ottawa, 1966. 38. S t a t i s t i c s Canada: 1981 Census of Canada: S e c l e c t e d S o c i a l and Economic C h a r a c t e r i s t c s - Vancouver. Cat. 95-978, M i n i s t e r of Supply and S e r v i c e s , Ottawa, 1983. 39. S t y b l o , K., E p i d e m i o l o g y of T u b e r c u l o s i s . The Hague, The N e t h e r l a n d s , VEB Gustav F i s c h e r V e r l a g Jena, 1984. 40. 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 B r i t i s h Columbia. Annual R e p o r t , 1953. 41. 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 B r i t i s h Columbia. Annual R e p o r t , 1971. 42. 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 B r i t i s h Columbia. Annual R e p - i t s , 1977-82. 43. The P r o v i n c e . "T.B. Cases Spur C a l l f o r Mass T e s t i n g . " p 3, Wednesday, A p r i l 16, 1985.. 44. The P r o v i n c e . " P a t r o n s W i l l P i c k e t P a t r i c i a . " p 3, F r i d a y , F ebruary 28, 1986. 90 45. T u b e r c u l o s i s Chemotherapy C e n t r e , Madras: "A Concurrent Comparison of Home and Sanatorium Treatment of Pulmonary T u b e r c u l o s i s i n South I n d i a . " WHO P u b l i c H e a l t h Papers , 21:51-65, 1959. 46. T u b e r c u l o s i s Chemotherapy C e n t r e , Madras: " I n t e r m i t t e n t Treatment of Pulmonary T u b e r c u l o s i s . A Concurrent Comparison of Twice-Weekly I s o n i a z i d P l u s S t r e p t o m y c i n and D a i l y I s o n i a z i d P l u s p - A m i n o s a l i c y l i c A c i d i n D o m i c i l l i a r y Treatment." Lancet , 1078-1080, 1963. 47. T u b e r c u l o s i s Chemotherapy C e n t r e , Madras: "A C o n t r o l l e d Comparison of a Twice-Weekly and Three Once-Weekly Regimens i n the I n i t i a l Treatment of Pulmonary T u b e r c u l o s i s . " WHO B u l l e t i n , 43: 143-206, 1970. 48. Vancouver Sun. "Mayor Asks H o t e l s to H a l t E v i c t i o n s . " Page A3, Thursday, February 27, 1986. 49. Waksman, S.A., The Conquest of T u b e r c u l o s i s . , B e r k e l y , U n i v e r s i t y of C a l i f o r n i a P r e s s , 1964. 50. WHO C o l l a b o r a t i n g Centre f o r T u b e r c u l o s i s Chemotherapy, Prague, " C o m p a r i t i v e Study of D a i l y and Twice-Weekly C o n t i n u a t i o n Regimes of T u b e r c u l o s i s Chemotherapy I n c l u d i n g a Comparison of Two D u r a t i o n s of Sanatorium Treatment. F i r s t R e p o r t : R e s u l t s a t 12 Months." WHO  B u l l e t i n , 45:135-143, 1971. 91 APPENDICES 92 APPENDIX B MAP OF THE STUDY AREA SHOWING RECODED AREAS 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0096764/manifest

Comment

Related Items