title: Psychological distress and its relationship with non-adherence to TB treatment: a multicentre study.
abstract: BACKGROUND
  The successful cure of tuberculosis (TB) is dependent on adherence to treatment. Various factors influence adherence, however, few are easily modifiable. There are limited data regarding correlates of psychological distress and their association with non-adherence to anti-TB treatment.
  
  
  METHODS
  In a trial of a new TB test, we measured psychological distress (K-10 score), TB-related health literacy, and morbidity (TBscore), prior to diagnosis in 1502 patients with symptoms of pulmonary TB recruited from clinics in Cape Town (n = 419), Harare (n = 400), Lusaka (n = 400), Durban (n = 200), and Mbeya (n = 83). Socioeconomic, demographic, and alcohol usage-related data were captured. Patients initiated on treatment had their DOTS cards reviewed at two-and six-months.
  
  
  RESULTS
  22 %(95 % CI: 20 %, 25 %) of patients had severe psychological distress (K-10 ≥ 30). In a multivariable linear regression model, increased K-10 score was independently associated with previous TB [estimate (95 % CI) 0.98(0.09-1.87); p = 0.0304], increased TBscore [1(0.80, 1.20); p <0.0001], and heavy alcohol use [3.08(1.26, 4.91); p = 0.0010], whereas male gender was protective [-1.47(-2.28, -0.62); p = 0.0007]. 26 % (95 % CI: 21 %, 32 %) of 261 patients with culture-confirmed TB were non-adherent. In a multivariable logistic regression model for non-adherence, reduced TBscore [OR (95 % CI) 0.639 (0.497, 0.797); p = 0.0001], health literacy score [0.798(0.696, 0.906); p = 0.0008], and increased K-10 [1.082(1.033, 1.137); p = 0.0012], and heavy alcohol usage [14.83(2.083, 122.9); p = 0.0002], were independently associated. Culture-positive patients with a K-10 score ≥ 30 were more-likely to be non-adherent (OR = 2.290(1.033-5.126); p = 0.0416].
  
  
  CONCLUSIONS
  Severe psychological distress is frequent amongst TB patients in Southern Africa. Targeted interventions to alleviate psychological distress, alcohol use, and improve health literacy in newly-diagnosed TB patients could reduce non-adherence to treatment.
authors.affiliation: Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa. grant.theron@uct.ac.za.
authors.forename: Grant
authors.initials: G
authors.lastname: Theron
authors.affiliation: Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa. jonny.g.peter@gmail.com.
authors.forename: Jonny
authors.initials: J
authors.lastname: Peter
authors.affiliation: Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. lzijenah@gmail.com.
authors.forename: Lynn
authors.initials: L
authors.lastname: Zijenah
authors.affiliation: University Teaching Hospital, Lusaka, Zambia. duncanchanda@gmail.com.|Institute for Medical Research & Training, Lusaka, Zambia. duncanchanda@gmail.com.
authors.forename: Duncan
authors.initials: D
authors.lastname: Chanda
authors.affiliation: National Institute of Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania. cmangu@nimr-mmrc.org.
authors.forename: Chacha
authors.initials: C
authors.lastname: Mangu
authors.affiliation: National Institute of Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania. pclowes@mmrp.org.|Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany. pclowes@mmrp.org.
authors.forename: Petra
authors.initials: P
authors.lastname: Clowes
authors.affiliation: National Institute of Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania. Rachow@lrz.uni-muenchen.de.|Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany. Rachow@lrz.uni-muenchen.de.
authors.forename: Andrea
authors.initials: A
authors.lastname: Rachow
authors.affiliation: Department of Medicine, University of Cape Town, Cape Town, South Africa. lesosky@gmail.com.
authors.forename: Maia
authors.initials: M
authors.lastname: Lesosky
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany. hoelscher@lrz.uni-muenchen.de.|German Centre for Infection Research (DZIF), Munich, Germany. hoelscher@lrz.uni-muenchen.de.
authors.forename: Michael
authors.initials: M
authors.lastname: Hoelscher
authors.affiliation: South African Medical Research Council, Durban, South Africa. alexanderpym@hotmail.com.|KwaZulu Research Institute for Tuberculosis and HIV (K-RITH), Durban, South Africa. alexanderpym@hotmail.com.
authors.forename: Alex
authors.initials: A
authors.lastname: Pym
authors.affiliation: University Teaching Hospital, Lusaka, Zambia. pbmwaba2000@yahoo.com.|Institute for Medical Research & Training, Lusaka, Zambia. pbmwaba2000@yahoo.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Mwaba
authors.affiliation: Biomedical Research & Training Institute, Harare, Zimbabwe. pmasonzim@gmail.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Mason
authors.affiliation: Population Health, Health Systems and Innovation (PHHSI)/HIV/STIs and TB (HAST) Research Programmes, Human Sciences Research Council, Cape Town, South Africa. pnaidoo@hsrc.ac.za.
authors.forename: Pamela
authors.initials: P
authors.lastname: Naidoo
authors.affiliation: Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa. anil.pooran@gmail.com.
authors.forename: Anil
authors.initials: A
authors.lastname: Pooran
authors.affiliation: McGill International TB Centre & Department of Epidemiology & Biostatistics, McGill University, Montreal, Canada. dhjsohn@gmail.com.
authors.forename: Hojoon
authors.initials: H
authors.lastname: Sohn
authors.affiliation: McGill International TB Centre & Department of Epidemiology & Biostatistics, McGill University, Montreal, Canada. madhukar.pai@mcgill.ca.
authors.forename: Madhukar
authors.initials: M
authors.lastname: Pai
authors.affiliation: Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa. Dan.Stein@uct.ac.za.
authors.forename: Dan J
authors.initials: DJ
authors.lastname: Stein
authors.affiliation: Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, H47 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa. Keertan.dheda@uct.ac.za.
authors.forename: Keertan
authors.initials: K
authors.lastname: Dheda
mesh_terms: D000328:Adult; D000428:Alcohol Drinking / Q000453:epidemiology* / Q000523:psychology; D000995:Antitubercular Agents / Q000627:therapeutic use*; D001007:Anxiety / Q000453:epidemiology / Q000523:psychology; D003863:Depression / Q000453:epidemiology / Q000523:psychology; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D015999:Multivariate Analysis; D012737:Sex Factors; D013019:South Africa / Q000453:epidemiology; D013315:Stress, Psychological / Q000453:epidemiology* / Q000523:psychology; D013636:Tanzania / Q000453:epidemiology; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology; D015024:Zambia / Q000453:epidemiology; D015030:Zimbabwe / Q000453:epidemiology; D016903:Drug Monitoring
chemical_list: D000995:Antitubercular Agents