|Year : 2021 | Volume
| Issue : 1 | Page : 12-20
Demographic and clinical factors affecting health-related quality of life in patients with pulmonary tuberculosis in Jazan, Saudi Arabia
Heba Mohmmed Shalabey1, Hedya Said Mohammed2, Majid Darraj3, Azza Mohammed Hassan4
1 Lecturer of Chest Diseases, Department of Pulmonary Medicine, School of Medicine, Ain Shams University,Assistant Professor of Chest Diseases, Faculty of Medicine, Jazan University, Egypt
2 Lecturer of Chest Diseases, Department of Pulmonary Medicine, Faculty of Medicine, Ain Shams University, Egypt
3 Assistant Professor, Department Of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
4 Assistant Professor, Department of Community, Occupational, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||01-Mar-2020|
|Date of Decision||12-May-2020|
|Date of Acceptance||29-Jul-2020|
|Date of Web Publication||27-Mar-2021|
Hedya Said Mohammed
Department of Pulmonary Medicine, Faculty of Medicine Ain Shams University, Abbassyia, 11566, Cairo
Source of Support: None, Conflict of Interest: None
Introduction Despite the abundant literature about health-related quality of life (HRQOL) in patients with active pulmonary tuberculosis (PTB) and the scarcity of published literature in KSA, this is the first study to assess the 6-min walk test, sputum examination, and tuberculin test for patients with PTB in correlation with HRQOL domains.
Patients and methods The study aimed to measure HRQOL among patients with PTB and to identify the demographic and the clinical factors that may affect HRQOL. A cross-sectional study using the WHO-BREF 26-item questionnaire was carried out on 114 patients with PTB at a secondary hospital in Jazan from September 2018 to September 2019.
Results There was a significant association between the overall perception of health and health status of patients. The social domain had the lowest scores, followed by the environmental, psychological, and lastly, the physical domains. The influence of comorbidities has a significant correlation with the environmental and social domains for HRQOL in patients with PTB. A significant correlation was found between the 6-min walk test and physical and psychological domains. However, sputum smear examination and tuberculin test did not significantly relate to HRQOL domains.
Conclusion A decrease of the four domains in the assessment of the HRQOL in PTB has been noted in relation to some demographic and clinical factors.
Keywords: health-related quality of life, pulmonary tuberculosis, 6-min walk test, sputum examination, tuberculin test
|How to cite this article:|
Shalabey HM, Mohammed HS, Darraj M, Hassan AM. Demographic and clinical factors affecting health-related quality of life in patients with pulmonary tuberculosis in Jazan, Saudi Arabia. Egypt J Chest Dis Tuberc 2021;70:12-20
|How to cite this URL:|
Shalabey HM, Mohammed HS, Darraj M, Hassan AM. Demographic and clinical factors affecting health-related quality of life in patients with pulmonary tuberculosis in Jazan, Saudi Arabia. Egypt J Chest Dis Tuberc [serial online] 2021 [cited 2021 Jun 13];70:12-20. Available from: http://www.ejcdt.eg.net/text.asp?2021/70/1/12/312138
| Introduction|| |
Tuberculosis (TB) is one of the oldest infectious diseases known to affect humans, and in spite of the new modalities in the treatment strategies and observations, it remains one of the most considerable leading causes of death worldwide .
It is estimated that approximately one-third of the world population has Mycobacterium tuberculosis infection. The WHO estimates that close to 54 million TB deaths were precluded between 2000 and 2017 because of the improved disease prevention and management service delivery . In KSA, 64 345 TB cases were recorded to the National TB Control Program (NTBCP) during 1991–2010 . However, in 2018, it was 3400, with a rate of 10 patients per 100 000 population  Although laboratories or clinical tests provide important information regarding the disease, it is impossible to separate the disease from the individual’s personal and social context, especially a chronic disease . Much attention has been given to the clinical outcomes of therapy and microbiological cures . However, there is an ever-increasing interest in evaluating the health-related quality of life (HRQOL) with chronic diseases. As a result, improved daily functioning and HRQOL among patients has turned into a therapeutic objective .
Quality of life is one of the indispensable criteria for the awareness of health care interventions such as morbidity, mortality, fertility, and disability . HRQOL represents the bind between HRQOL and individual health status. It is considered to be multidimensional, encompassing physical and occupational function, emotional status, social interaction, and somatic sensations . Keeping in view these dimensions, HRQOL questionnaires aim to provide a broad, comprehensive, and subjective measure of disease effect .
In light of TB as a serious problem in the KSA, the evaluation of HRQOL among patients with pulmonary tuberculosis (PTB) in this country with different nationalities should be conducted on regular basis to study the multifactorial aspects in relation to HRQOL.
A vital tool used to assess HRQOL at individual and population levels is the brief form WHO-HRQOL 26 version which focuses on patients’ environmental, physical, social, and psychological evaluation. This study assessed the HRQOL in patients with active PTB in Chest Hospital, Jazan, Saudi Arabia, assessing the relation between HRQOL and sputum smear examination, Mantoux test, and 6-min walk test (6MWT). These may assist health care professionals to understand the health effect of TB disease on QOL of patients and to improve patients’ health and well-being.
| Patients and methods|| |
A descriptive cross-sectional study was carried out at the Chest Hospital in Jizan, Saudi Arabia. Jizan is a port city and the capital of the Jazan region, which lies in the southwest corner of Saudi Arabia and the north border with Yemen. The study was approved by the Ethical Committee of the Ministry of Health in Jazan on May 29, 2018. All participants were informed about the voluntary nature of participation and confidentiality of data with written consent for the patients who agreed to be enrolled in the study.
The study was done on 114 patients diagnosed with active PTB and who were receiving treatment by the National TB Control Program, Ministry of Health, KSA, after satisfying the inclusion criteria. Patients above 14 years who had clinical symptoms and signs for PTB associated with laboratory and radiological features of TB and started the initiation phase of therapy were included in the study. Excluded patients were those with extrapulmonary TB and patients with associated psychiatric diseases.
The interview questionnaire was used asking about sociodemographic characteristics like age, sex, marital status, nationality, level of education, current habits, and presence of comorbid conditions.
Clinical examination and investigations
Chest radiographic posteroanterior view, Mantoux test, sputum smear examination, and 6MWT were performed at the time of diagnosis.
Measurement of BMI: body weight and height were measured to calculate BMI of the participant according to the WHO guidelines .
It is an intradermal skin test that has been relied upon for the diagnosis of persons who have been sensitized by M. tuberculosis .
6-min walk test
After the tuberculin test, all patients underwent 6MWTs according to the American Thoracic Society protocol. 6MWT was performed in the hospital by a well-trained technician. The technician is certified in cardiopulmonary resuscitation with minimum training in basic life support through the Saudi Health Association-approved cardiopulmonary resuscitation course .
The WHOQOL-BREF Field Trial Version has therefore been developed to provide a short-form quality-of-life assessment that looks at the important domain level, using all available data from the Field Trial Version of the WHOQOL-100. The WHOQOL-BREF contains a total of 26 questions .
Scoring of the WHOQOL-BREF: the WHOQOL-BREF produces four domain scores. Two items are examined separately: question 1 asks about an individual’s overall perception of the quality of life, and question 2 asks about an individual’s overall perception of his or her health. Domain scores are scaled in a positive direction (i.e. higher scores denote the higher quality of life). The mean score of items within each domain is used to calculate the domain score .
Analysis of data was done using Statistical Package for Social Science (IBM SPSS), version 23 (IBM Corp., Armonk, NY, USA). Quantitative variables were presented as mean with SD, and qualitative variables were presented as numbers and percentages. Student’s t-test and one-way analysis of variance test were used to compare the means of quantitative data between different groups. Pearson’s correlation coefficient (r) was used to measure the correlations between two continuous variables.
| Results|| |
A total of 114 patients participated in this study. Regarding demographic data, the age of the patients ranged between 16 and 91 years, with a mean of 35.8±17.4, BMI ranged from 11.30 to 31.60 kg/m2, and 53.5% were underweight. In this study, 70.2% of the patients were males and 29.8% were females. A total of 45 (39.5%) patients had primary or preparatory education and 35 (30.7%) were illiterate. Overall, 67 (58.8%) patients were single and 41.2% were married. Saudi patients represented 36.8% of studied patients, and 46.5% had no comorbidities. Most patients were underweight (53.5%). Tuberculin test was positive in 73% of patients, and sputum smear for AFB was positive in 64.2%. [Table 1] describes the association between patients’ characteristics and both the overall perception of QOL and overall perception of health. No significant association was found between the overall HRQOL score and patients’ characteristics, except for education [higher education was associated with higher scores (P<0.05)], marital status [married patients had higher scores than singles (P<0.05)], and presence of comorbidities [patients with associated comorbidities had lower scores than those without comorbidities (P<0.05)]. Moreover, there was no significant association between the overall perception of health and different patients’ characteristics except for health status, as patients with fair and good health status had higher scores than patients with poor and very poor health status (P<0.05). Moreover, in [Table 2], there was no significant association between physical health domain and different patients’ characteristics, except for the education level, where higher education level was associated with higher scores (P<0.05). Regarding the relation between psychological health domain and different patients’ characteristics, as in [Table 3], no significant association was found, except for age [higher age associated with higher scores (P<0.05)] and health status [fair and good health status had higher scores than poor health status (P<0.05)]. The relation between social relationship domain and different patients’ characteristics ([Table 4]) showed a significant associated with patient’s sex [females had higher scores than males (P<0.05)], educational level [patients with higher educational level had higher scores (P<0.05)], marital status [married patients had higher scores than singles (P<0.05)], and presence of comorbidities [patients with comorbidities had lower scores (P<0.05)]. In [Table 5], the relation between the environment domain and different patients’ characteristics showed there was a significant association with patient’s sex [females had higher scores than males (P<0.05)], educational level [patients with higher educational level had higher scores (P<0.05)], marital status [married patients had higher scores than singles (P<0.05)], and presence of comorbidities [patients with comorbidities had lower scores (P<0.05)].
|Table 1 Association between patients’ characteristics and both overall perception of HRQOL and overall perception of health|
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|Table 2 Relation between demographic and clinical data and physical health domain|
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|Table 3 Relation between demographic and clinical data and psychological health domain|
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|Table 4 Relation between demographic and clinical data and social relationships domain|
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|Table 5 Relation between demographic and clinical data and environment domain|
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| Discussion|| |
Jazan region showed a high incidence of TB. Jazan, being a border area, houses immigrants from countries like Yemen and Africa (via the sea from Ethiopia). Immigrants usually stay in an unhealthy housing environment with difficult access to health care services, which could play an important role in the high incidence of TB in this provenance .
Our study of TB in Jazan revealed four significant findings: first, TB remains an important public health problem in Jazan affecting all age groups (Saudi and non-Saudi alike); second, non-Saudi patients had nearly twice the TB incidence compared with Saudi patients throughout the study; third, non-Saudi patients with TB were immigrants from high TB endemic countries in the world, which could be attributed to the location of Jazan; and fourth, incidence of males was higher than females .
The total sample size of the study was 114 patients with pulmonary TB; three patients among them were human immunodeficiency virus (HIV) positive. The majority of the patients enrolled in the study were between 25 and 35 years old (31.6%) including the productive age group, with a higher incidence of TB in males (70.2%) than females (29.8%), which was similar to other studies done in KSA . Also, this study finding was related to the studies done from different endemic countries such as Yemen , India , Iran , Indonesia , Nigeria , and Uganda .
This study revealed that TB was higher among single (58.8%) than married (41.2%) patients, which was coincident with the studies in Yemen  and Iran  and could be related to the fact that the majority of the patients were immigrants in Jazan. On the contrary, a study done in Indonesia  showed a higher incidence among married than non-married patients which could be explained by the difference in the cultural and socioeconomic characteristics between the two countries.
Among the patients with PTB in this study, most patients had been educated till the primary and preparatory levels (39.5%), with a higher incidence among the illiterate patients (30.7%) and lower among the university-educated patients. In contrast to a study done by Wahyuni et al. in 2018  in Indonesia, which could be different in culture, Jazan had high immigrants from other countries with low socioeconomic levels. The preponderance group in the study was foreigners (63.2%), and only 36.8% were Saudi; this is similar to a study done in Canada by Bauer et al. . The higher percentage of foreigners with TB in the sample could be attributed to a higher incidence of foreigners and immigrants among Saudi Arabia, who represent 31% of the total population. Many factors could play a role in the explanation of this incidence as most of them experienced stress and social isolation in addition to the majority who came from endemic areas of TB.
The majority of the patients were underweight (53.5%); this is coincident with the WHO annual report 2019 , which notified that patients with PTB were underweight. Nutrition disequilibrium (e.g. underweight) can impair the immune system (e.g. T-cell suppression) and thus might affect TB incidence. Prior studies have demonstrated that the incidence of TB infection decreased with increasing BMI. Nutrition disequilibrium may also affect treatment outcomes in patients with TB owing to the decline of immunity .
The preponderance group in the study were foreigners (63.2%), and only 36.8% were Saudi, which is similar to a study done in Canada by Aggarwal et al. . This could be attributed to a higher incidence of foreigners and immigrants among Saudi Arabia who represent 31% of the total population, who came seeking for work and money to be given back to their family. Many factors could play a role in the explanation of this incidence as most of them experienced stress and social isolation besides great changes in the environmental conditions. This also could be attributed to the fact that the majority came from TB endemic areas. On this assumption, additional support that targeted these stressors as a part of TB care, especially at the time of diagnosis, may improve HRQOL, particularly mental well-being.
However, it is much beneficial to correlate clinical aspects of PTB with HRQL. In the present study, we used a simple universal score (WHOQOL-BREIF scale), containing 36 questions to assess the HRQOL in patients with PTB. Furthermore, its generic nature is well suited to the evaluation of the disease such as PTB, which has a considerable systematic effect. The overall perception of the HRQOL in patients with PTB was highly significant by neither poor nor good (50%). This was clearly observed in the significant variation of the results obtained from different studies. It was also concordant with the studies done in Yemen 2016  and Iran 2019 , which showed that HRQOL perception was low.
Despite the abundant literature about HRQOL in patients with PTB in other parts of the globe and the scarcity of published literature reporting HRQOL in patients with PTB in Saudi Arabia, this is the first study to assess the 6MWT and sputum examination for patients with PTB in correlation with various HRQOL domains in a trial to correlate HRQOL with clinical data. A significant correlation was found between the 6MWT and physical and psychological domains. Moreover, sputum smear examination did not significantly relate to the four domains. This could explain that the infectivity of the disease did not affect the HRQOL.
Our study found no significant correlation between the tuberculin test and the four domains of HRQOL in patients with PTB. In addition, the influence of comorbidities was appraised in this study, as 53.5% of patients had comorbidities, which showed a significant correlation with the environmental and social domains for HRQOL in patients with PTB. It is well known that comorbidities and TB affect the social interactions and relationships among environmental interactions. Partly because of the stigma associated with TB in Saudi Arabia, besides the fact that most patients with PTB came from countries with poor resources, it is not surprising that the social relationship and environmental domains were affected more in the patients with PTB and different comorbidities.
The HRQOL obtained from patients with PTB differs from one study to another depending on the location and the culture of the study. Moreover, this was clearly observed in the significant variation of the results obtained from various studies. Our study finds that all HRQOL of the four domains was low at the time of diagnosis, whereas others indicate low scores only in a few domains. Similar studies were conducted by Aggarwal et al.  and Asuquo et al.  where the overall HRQOL was found to be somewhat impaired at the initial diagnosis.
This study showed that the social domain was the lowest domain followed by the environmental, psychological, and lastly the physical domains from the worst to the best (8.81±1.95, 9.67±1.59, 9.94±1.71, and 10.45±2.37, respectively). In contrast to other domains, both social and environmental domains showed the lowest scores among the domains in patients with PTB who were affected by similar factors, which are sex, education, marital status, and comorbidities.
It is not surprising that the social relationships domain in non-Saudi patients with PTB was affected more among immigrants, as there is a social avoidance from most of their friends and colleagues and even from their work managers as patients with PTB are perceived as a possible source of infection. Detachment from loved ones is a social struggle as individuals work away from their families and friends, which was similar to a study done in Saudi Arabia in 2018 .
Similarly, studies in India  and Iran  revealed that both social and environmental domains had the lowest score in diagnosed patients with PTB. On the contrary, the study done in Al Damam Central Hospital in Saudi Arabia by Al-Qahtani et al. in 2014  showed that the physical domain was the lowest among the four domains. Not only the studies in Saudi Arabia but also some studies in Yemen  and Uganda  also showed that the physical domain was the lowest among domains. The difference could be explained by the sedentary lifestyle and the lack of awareness of the importance of physical exercises, which could be associated with climate conditions of desert and the harshness of weather. However, our study showed that the physical domain is the highest domain measured during the initial diagnosis of patients with PTB which could explain that most patients with PTB are foreigners who travel to Saudi Arabia for working and most of them had good physical activity.
The psychological domain that includes the aspects of an individual mood and emotional well-being was low similar to other studies ,,,.
There are a few limitations in this study that may have some potential effect on the results. The study neither includes nor explores the differences in HRQOL among the patients in specific groups like latent TB and extrapulmonary TB.
| Conclusion|| |
Actually, there are discrete factors that intimidate the HRQOL of patients with TB. A decrease in the four domains in the assessment of the HRQOL in PTB has been noted in relation to multiple demographic and clinical factors. This study reported poor HRQOL among patients with TB in Jazan area, Saudi Arabia. The results also affirm the findings of other existing data that some demographic qualities and social and clinical attributes of the individual affect the overall HRQOL as well as the different HRQOL dimensions among patients with TB.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO. The End TB Strategy: Global Strategy and Targets for Tuberculosis Prevention, Care and Control After 2015. Geneva: WHO; 2015.
WHO. Global Tuberculosis Report 2018. Geneva: WHO; 2018.
Al-Orainey I, Alhedaithy MA, Alanazi AR, Barry MA, Almajid FM. Tuberculosis incidence trends in Saudi Arabia over 20 years: 1991-2010. Ann Thorac Med 2013; 8:148.
] [Full text]
WHO_HQ_Reports-G2-PROD-EXT-TBCountryProfile. Saudi Arabia 2018 Tuberculosis profile, Estimates of TB and MDR-TB burden
Aggarwal AN, Health-related quality of life: a neglected aspect of pulmonary tuberculosis,. Lung India 2010; 27:1.
Asuquo AE, Pokam BT, Adindu A, Ibeneme E, Obot V. Health-related quality of life (HRQoL) of tuberculosis (TB) patients in Akwa Ibom State, Nigeria,. J Tubercul Res 2014; 2:199.
Malik M, Nasir R, Hussain A. Health related quality of life among TB patients: question mark on performance of TB DOTS in Pakistan,. J Trop Med 2018; 2018:2538532.
Nikiphorou E, Norton S, Young A, Dixey J, Walash D, Helliwell H, Kiely P. The association of obesity with disease activity, functional ability and quality of life in early rheumatoid arthritis: data from the Early Rheumatoid Arthritis Study/Early Rheumatoid Arthritis Network UK prospective cohorts. Rheumatology 2018; 57:1194–1202.
W. Group, Study protocol for the World Health Organization project to develop a Quality of Life assessment instrument (WHOQOL),. Qual Life Res 1993; 2:153–159.
Schipper H, Clinch J, Olweny C. Quality of life studies: definitions and conceptual issues. Spilker B, editor. Quality of Life and Pharmacoeconomics in Clinical Trials. 2014. 11–23.
E. C. Who. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies, . Lancet (London, England) 2004; 363:157.
A. T. Society, C. f. D. Control, and Prevention. Diagnostic standards and classification of tuberculosis in adults and children,. Am J Respir Crit Care Med 2000; 161:1376–1395.
A. T. Society. ATS statement: guidelines for the six-minute walk test,. Am J Respir Crit Care Med 2002; 166:111–117.
Sule AG, Odeigah OS, Alabi KM, Issa BA, Shittu RO, Joseph AI et al.
Quality of life of patients with tuberculosis in a Nigerian Teaching Hospital,. Anxiety 2014. 12:14.
WHOQOL-BREF. Introduction, administration, scoring and generic version of the assessment field trial versiondecember 1996 Programme on Mental Health World Health Organization, Geneva.
Alvi A, Fatima N, Jerah AA, Rizwan M, Hobani YH, Sunosi RA et al.
Correlation between resistin, tuberculosis and khat addiction: a study from south western province of Saudi Arabia, PLoS One 2015; 10.
Abouzeid MS, Al Hakeem RF, Memish ZA. Mortality among tuberculosis patients in Saudi Arabia (2001–2010),. Ann Saudi Med 2013; 33:247–252.
Jaber AAS, Khan AH, Sulaiman SAS, Ahmad N, Anaam MS. Evaluation of health-related quality of life among tuberculosis patients in two cities in Yemen,. PLoS One 2016 11:e015258.
Aggarwal A, Gupta D, Janmeja A, Jindal S. Assessment of health-related quality of life in patients with pulmonary tuberculosis under programme conditions, Int J Tuberc Lung Dis 2013; 17:947–953.
Salehitali S, Noorian K, Hafizi M, Dehkordi AH. Quality of life and its effective factors in tuberculosis patients receiving directly observed treatment short-course (DOTS), J Clin Tubercul Other Mycobact Dis 2019; 15:100093.
Wahyuni A, Soeroso N, Harahap J, Amelia R, Alona I. Quality of life of pulmonary TB patients after intensive phase treatment in the health centers of Medan City, Indonesia.
Kisaka SM, Rutebemberwa E, Kasasa S, Ocen F, Nankya-Mutyoba J. Does health-related quality of life among adults with pulmonary tuberculosis improve across the treatment period? A hospital-based cross sectional study in Mbale Region, Eastern Uganda,. BMC Res Notes 2016; 9:467.
Bauer M, Bauer M, Ahmed S, Benedetti A, Greenaway C, Lalli M et al.
Health-related quality of life and tuberculosis: a longitudinal cohort study,. Health Qual Life Outcomes 2015; 13:65.
WHO, Global Tuberculosis Report 2013. Geneva: WHO; 2019.
Yen YF, Chuang PH, Yen MY, Lin SY, Chuang P, Yuan MJ et al.
Association of body mass index with tuberculosis mortality: a population-based follow-up study. Medicine 2016; 95:e2300.
Dhelaimi GO, Alsaedi TS, Alharbi MO, Alkaraiem F, Altarjami AS, Alkaraiem AA, Inocian EP. Multidimensional health-related quality-of-life among patients with pulmonary tuberculosis in Saudi Arabia. World 2018; 3:48–56.
Al-Qahtani MF, Mahalli AAE, Al Dossary N, Al Muhaish A, Al Otaibi S, Al Baker F. Health-related quality of life of tuberculosis patients in the Eastern Province, Saudi Arabia. J Taibah Univ Med Sci 2014; 9:311–317.
Ramkumar S, Vijayalakshmi S, Seetharaman N, Pajanivel R, Lokeshmaran A. Health-related quality of life among tuberculosis patients under Revised National Tuberculosis Control Programme in rural and urban Puducherry, Indian J Tubercul 2017; 64:14–19.
Chamla D. The assessment of patients’ health-related quality of life during tuberculosis treatment in Wuhan, China,. Int J Tuberc Lung Dis 2004; 8:1100–1106.
Dhingra V, Rajpal S. Health related quality of life (HRQL) scoring (DR-12 score) in tuberculosis − additional evaluative tool under DOTS. J Commun Dis 2005; 37:261–268.
Abouzeid MS, Zumla AI, Felemban S, Alotaibi B, O’Grady J, Memish ZA. Tuberculosis trends in Saudis and non-Saudis in the Kingdom of Saudi Arabia − a 10 year retrospective study (2000–2009). PLoS One 2012; 7:e39478.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]