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UBC Theses and Dissertations

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


This study is an evaluation (in terms of attendance compliance) of the community based tuberculosis out-patient program at the Downtown Community Health Clinic (DCHC) in Vancouver. Treatment compliance is a measure of the degree of adherence to a treatment regime established by care givers whereas attendance compliance is concerned only with attendance to clinic appointments. Because treatment at the DCHC is supervised, attendance compliance can be closely associated with treatment compliance. The DCHC was established in Vancouver's Downtown-Eastside district in 1980 in an effort to reduce tuberculosis rates among the skid-row population. Prior to 1980, skid-row patients were required to attend the Willow Chest Clinic (WCC), located outside the downtown area. Prior to 1979, hospital-based out-patient therapy at the WCC lasted 18-24 months and was unsupervised. Community-based treatment at the DCHC generally lasts 9 months. Treatment is supervised by a tuberculosis nurse at the DCHC who plays a key role in promoting compliance. The evaluation is based on a comparison of attendance to appointments at both these clinics. As background for the evaluation, a model of tuberculosis epidemiology in developed countries in general and Canada in particular is described. The model shows that as tuberculosis rates have fallen, three main groups at high-risk for the disease have emerged; aboriginal people, immigrants from countries with high rates, and non-Native residents of urban skid-row districts. These three groups are well represented in Vancouver's skid-row districts and account for most of the patient population at the DCHC. The study outlines how tuberculosis treatment strategies have evolved in relation to technological developments and the changing epidemiology of tuberculosis in developed countries. The adaptation of modern tuberculosis treatment methods in B.C. and Vancouver is traced, culminating with the development of hospital based out-patient treatment at the WCC and community based outpatient treatment at the DCHC. The tuberculosis epidemiology of Vancouver's skid-row is then described in relation to the socio-demographic conditions of the area. The well known association between tuberculosis and poverty is discussed. Socio-demographic upheavals in the area related to Vancouver's 1986 Worlds Fair are described and their possible effects on the skid-row tuberculosis problem outlined. This background, which outlines the socio-demography of the tubercular population and shows the rationale behind their treatment system (at the DCHC), sets the stage for a discussion on compliance. Tubercular patients must take drugs regularly for a long period of time. This requires a lengthy and disciplined interaction with the treatment system. For the generally poor and often alienated tubercular population on skid-row, this may pose particular difficulties. Attendance to clinic appointments in order to receive drugs may be the single most important factor in a successful treatment outcome. With the pivotal role of attendance compliance established, major socio-demographic factors predictive for attendance compliance at the DCHC are determined and the DCHC is evaluated by comparing it's ability to promote attendance compliance with the WCC. A retrospective case control study design is used in the evaluation comparing the DCHC clients for the years 1981-83 with matched controls who attended the WCC in the years 1977-79. Results of the evaluation indicate attendance compliance of patients at the DCHC was significantly better than at the WCC. Furthermore, four major factors predictive for compliance were identified. These were, in order of importance, patient's address in relation to the clinic, patient's age, severity of diagnosis and race.

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