The long term effect of pulmonary tuberculosis on income and employment in a low income, urban setting

Abstract

Background: Mitigating the socioeconomic impact of tuberculosis (TB) is key to the WHO End TB Strategy. However, little known about socioeconomic well-being beyond TB-treatment completion. In this mixed-methods study, we describe socioeconomic outcomes after TB-disease in urban Blantyre, Malawi, and explore pathways and barriers to financial recovery.

Methods: Adults ≥15 years successfully completing treatment for a first episode of pulmonary TB under the National TB Control Programme were prospectively followed up for 12 months. Socioeconomic, income, occupation, health seeking and cost data were collected. Determinants and impacts of ongoing financial hardship were explored through illness narrative interviews with purposively selected participants.

Results: 405 participants were recruited from February 2016 to April 2017. Median age was 35 years (IQR: 28-41), 67.9% (275/405) were male, and 60.6% (244/405) were HIV-positive. Employment and incomes were lowest at TB-treatment completion, with limited recovery in the following year: fewer people were in paid work (63.0% (232/368) vs 72.4% (293/405), p=0.006), median incomes were lower (US$44.13 (IQR: US$0-US$106.15) vs US$72.20 (IQR: US$26.71-US$173.29), p<0.001), and more patients were living in poverty (earning <US$1.90/day: 57.7% (211/366) vs 41.6% (166/399), p<0.001) 1 year after TB-treatment completion compared with before TB-disease onset. Half of the participants (50.5%, 184/368) reported ongoing dissaving (use of savings, selling assets, borrowing money) and 9.5% (35/368) reported school interruptions in the year after TB-treatment completion. Twenty-one participants completed in-depth interviews. Reported barriers to economic recovery included financial insecurity, challenges rebuilding business relationships, residual physical morbidity and stigma.

Conclusions: TB-affected households remain economically vulnerable even after TB-treatment completion, with limited recovery in income and employment, persistent financial strain requiring dissaving, and ongoing school interruptions. Measures of the economic impact of TB disease should include the post-TB period. Interventions to protect the long-term health and livelihoods of TB survivors must be explored.

Keywords: Pulmonary tuberculosis; TB sequelae; health economics; post-TB lung disease; social determinants.

Figure 1

Participant flow diagram. TB, tuberculosis.

Figure 2

Self-reported occupation over time (prior to TB disease, at TB-treatment completion and 1-year after TB-treatment completion) stratified by HIV status.*HIV status available for 403 participants; ˆAd hoc work (eg, washing clothes, driving of minibuses, carrying goods for others). TB, tuberculosis.

Figure 3

Self-reported income over time (prior to TB disease, at TB-treatment completion and 1-year after TB-treatment completion) stratified by HIV status (median, IQR)^#.*Income data recorded in Malawian Kwacha with standardisation into US dollars by exchange rate at midpoint of pre-TB, baseline, and 1-year data collection intervals (online supplemental S1 appendix). ^#HIV status available for 403 participants. TB, tuberculosis

Figure 4

Proportion of participants incurring patterns of dissaving, during TB illness and treatment (n=372), and in the year after TB-treatment completion (n=360), stratified by urban wealth quintile (Q1–Q5)*. Q1 – Q5: richest to poorest urban wealth quintiles, calculated at TB treatment completion using the MalawiEquityTool 2012. *Wealth quintile data missing for n=33 participants.TB, tuberculosis.