Relative income and acute coronary syndrome: A population-based case-control study in Tirana, Albania Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 1 ORIGINAL RESEARCH Sex-differences in socioeconomic status and health-seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 Vera Kurti 1 , Hasan Hafizi 2 , Bardhyl Kurti 3 , Fitim Marku 3 , Donika Mema 2 , Genc Burazeri 2,4 1 Primary Health Care Centre “Dispensary for Chest Diseases”, Tirana, Albania; 2 University of Medicine, Tirana, Albania; 3 University Hospital of Trauma, Tirana, Albania; 4 Department of International Health, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands. Corresponding author: Dr. Vera Kurti Address: Rr. “Reshit Petrela”, Lgj. No. 4, Tirana, Albania; Telephone: +355672088785; E-mail: verakurti68@yahoo.com Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 2 Abstract Aim: There is little scientific evidence about the main determinants of sex discrepancies in tuberculosis rates in Albania. The aim of this study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in Albania, a transitional country in the Western Balkans. Methods: Our analysis involved all the new cases of pulmonary tuberculosis diagnosed in Albania during the period June 2012 – June 2013 (N=197; 69% males; overall mean age: 44±19 years). The recording and reporting system of tuberculosis cases was performed according to the WHO and EuroTB Surveillance guidelines. Information on socioeconomic characteristics of the patients, knowledge and attitudes about tuberculosis and access to health care was also collected. Logistic regression was used to assess the correlates of sex- differences among tuberculosis patients. Results: In multivariable-adjusted models, female sex was positively related to unemployment (OR=3.7, 95%CI=1.8-7.7), bad living conditions (OR=3.0, 95%CI=1.4-6.5), a longer distance to health care facility (OR=3.0, 95%CI=1.4-6.3), a lower level of knowledge about tuberculosis (OR=3.1, 95%CI=1.3-7.1) and a higher level of stigma against tuberculosis (OR=3.6, 95%CI=1.6-7.9). Conclusion: Our study informs about selected correlates of sex-differences in tuberculosis rates in post-communist Albania. Future studies should more vigorously explore determinants of sex-differences in tuberculosis rates in countries of the Western Balkans. Keywords: access to health care, Albania, case detection rate, health seeking behaviour, pulmonary tuberculosis, sex-differences, socioeconomic characteristics. Conflicts of interest: None. Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 3 Introduction To date, the information about determinants of sex-differences in tuberculosis occurrence is scant (1,2), notwithstanding the available evidence suggesting that, at a global level, tuberculosis affects men more frequently than women (3). In any case, tuberculosis remains a crucial public health issue at a global scale which, regardless of sex, affects mostly the disadvantaged young population subgroups (4,5). Hence, only for the year 2012, there were reported 8.6 million new tuberculosis cases and 1.3 million tuberculosis deaths (6). For the European region, the tuberculosis case notification rate in 2012 was substantially higher than the global average notification rates (7). However, the relatively higher case- notification rate in the European region on the whole does not necessarily apply for the former communist countries of the Western Balkans including Albania and Kosovo. Among all countries of the Western Balkans, Kosovo exhibits the highest incidence rate of tuberculosis (8,9). It should be noted that in both Albania and Kosovo, the tuberculosis notification rates resemble the respective incidence rates (8,9). Furthermore, both Albania and Kosovo have a low prevalence of HIV infection (8,9). However, the information about the sex-differences of tuberculosis rates in Albania is scarce. After the breakdown of the communist regime in 1990, Albania undertook a difficult journey from a rigid communist regime towards an open society (10,11). Nevertheless, the transition towards a democratic regime was associated with considerable socio-economic changes coupled with huge internal and external migration (12), which are believed to affect also the case-notification rates of tuberculosis. Yet, there are no recent scientific reports informing about the magnitude and determinants of tuberculosis in Albania. In this context, the aim of our study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients in Albania, a transitional country in the Western Balkans with a low prevalence of HIV/AIDS. Methods Design and study population A cross-sectional study was conducted including all new pulmonary tuberculosis patients diagnosed in Albania from June 2012 to June 2013. During this time period, overall, there were recorded 197 new tuberculosis patients in Albania (69% males and 31% females; overall mean age: 43.84±19.2 years). Data collection All the recorded tuberculosis data from registers of the Tuberculosis Program in Albania were used for this analysis. The recording and reporting system was performed according to the WHO and EuroTB Surveillance guidelines (13). All tuberculosis patients underwent a structured interview inquiring about factors related to access to health care, health seeking behavior and demographic and socioeconomic characteristics. Information about access to health care and health seeking behaviour included data on the distance to health care facility (dichotomized into: ≤10 km vs. >10 km), knowledge about tuberculosis (dichotomized into: yes vs. no) and stigma against tuberculosis (yes vs. no). Demographic and socioeconomic characteristics included age (dichotomized into: ≤45 vs. >45 years), gender (males vs. females), place of residence (urban areas vs. rural areas), employment status (dichotomized into: unemployed vs. employed/students/retired), educational attainment (dichotomized into: 0-8 years of formal schooling, vs. ≥9 years of formal schooling) and living conditions (dichotomized into: good/average vs. bad). Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 4 Statistical analysis Chi-square test was used to compare the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients. Binary logistic regression was used to assess sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients. Initially, crude (unadjusted) odds ratios (ORs), their respective 95% confidence intervals (95%CIs) and p-values were calculated. Subsequently, multivariable-adjusted ORs, their respective 95%CIs and p-values were calculated. Hosmer-Lemeshow test was used to assess the goodness of fit of the logistic regression models. In all cases, a p-value of ≤0.05 was considered statistically significant. Statistical Package for Social Sciences (SPSS, version 15.0) was used for all the statistical analysis. Results Table 1 presents the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in Albania by sex. Males were somehow younger than females, a finding which was not statistically significant (P=0.09). There was no sex-difference in the proportions of urban/rural residents. Conversely, the unemployment rate was considerably higher among females (59% vs. 29% in males, P<0.001). Similarly, the proportion of low-educated (0-8 years of formal schooling) and individuals with bad living conditions was higher among females than in males (77% vs. 60%, P=0.02 and 46% vs. 24%, P=0.02, respectively). A significantly higher proportion of females reported a longer distance to health care facility (>10 km) compared with their male counterparts (64% vs. 40%, respectively, P=0.002). The knowledge about tuberculosis was lower among females (66% vs. 81% in males, P=0.03), whereas the level of stigma against tuberculosis was considerably higher (71% vs. 49%, respectively, P=0.008) [Table 1]. Table 1. Distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in Albania by sex Variable Females (N=61) Males (N=136) P † Age: ≤45 years >45 years 27 (44.3) * 34 (55.7) 79 (58.1) 57 (41.9) 0.089 Place of residence: Urban areas Rural areas 24 (39.3) 37 (60.7) 64 (47.1) 72 (52.9) 0.354 Employment status: Unemployed Employed/students/retired 36 (59.0) 25 (41.0) 40 (29.4) 96 (70.6) <0.001 Educational level: 0-8 years ≥9 years 47 (77.0) 14 (23.0) 81 (59.6) 55 (40.4) 0.023 Living conditions: Good/average Bad 33 (54.1) 28 (45.9) 104 (76.5) 32 (23.5) 0.002 Distance to health facility: ≤10 km >10 km 22 (36.1) 39 (63.9) 82 (60.3) 54 (39.7) 0.002 Tuberculosis knowledge: Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 5 Yes No 40 (65.6) 21 (34.4) 110 (80.9) 26 (19.1) 0.029 Stigma: No Yes 18 (29.5) 43 (70.5) 69 (50.7) 67 (49.3) 0.008 * Absolute numbers and their respective column percentages (in parentheses). † P-values from the chi-square test. In crude (unadjusted) logistic regression models, there was no significant sex-difference in the age or place of residence of tuberculosis patients (Table 2). On the other hand, female gender was positively and significantly associated with unemployment (OR=3.5, 95%CI=1.8-6.5), a lower educational attainment (OR=2.3, 95%CI=1.2-4.5), bad living conditions (OR=2.8, 95%CI=1.5-5.2), a longer distance to health care facility (OR=2.7, 95%CI=1.4-5.0), a lower level of knowledge about tuberculosis (OR=2.2, 95%CI=1.1-4.4) and a higher level of stigma against tuberculosis (OR=2.5, 95%CI=1.3-4.7) [Table 2]. Table 2. Sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in Albania; crude/unadjusted odds ratios from binary logistic regression Variable OR * 95%CI * P * Age: ≤45 years >45 years 1.00 1.75 reference 0.95-3.21 0.073 Place of residence: Urban areas Rural areas 1.00 1.37 reference 0.74-2.53 0.315 Employment status: Employed/students/retired Unemployed 1.00 3.46 reference 1.84-6.45 <0.001 Educational level: ≥9 years 0-8 years 1.00 2.28 reference 1.15-4.54 0.019 Living conditions: Good/average Bad 1.00 2.76 reference 1.45-5.23 0.002 Distance to health facility: ≤10 km >10 km 1.00 2.69 reference 1.44-5.03 0.002 Tuberculosis knowledge: Yes No 1.00 2.22 reference 1.13-4.38 0.021 Stigma: No Yes 1.00 2.46 reference 1.29-4.69 0.006 * Crude/unadjusted odds ratios (OR: female vs. male), 95% confidence intervals (95%CI) and p-values from binary logistic regression. Upon simultaneous adjustment for all covariates (Table 3), female sex was positively related to unemployment (OR=3.7, 95%CI=1.8-7.7), bad living conditions (OR=3.0, 95%CI=1.4- 6.5), a longer distance to health care facility (OR=3.0, 95%CI=1.4-6.3), a lower level of Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 6 knowledge about tuberculosis (OR=3.1, 95%CI=1.3-7.1) and a higher level of stigma against tuberculosis (OR=3.6, 95%CI=1.6-7.9). Table 3. Sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in Albania; multivariable- adjusted odds ratios from binary logistic regression Variable OR * 95%CI * P * Age: ≤45 years >45 years 1.00 1.87 reference 0.88-3.98 0.102 Place of residence: Urban areas Rural areas 1.00 1.19 reference 0.57-2.50 0.645 Employment status: Employed/students/retired Unemployed 1.00 3.68 reference 1.78-7.65 0.001 Educational level: ≥9 years 0-8 years 1.00 1.64 reference 0.73-3.65 0.230 Living conditions: Good/average Bad 1.00 2.97 reference 1.36-6.48 0.006 Distance to health facility: ≤10 km >10 km 1.00 3.00 reference 1.42-6.34 0.004 Tuberculosis knowledge: Yes No 1.00 3.06 reference 1.33-7.08 0.009 Stigma: No Yes 1.00 3.57 reference 1.62-7.88 0.002 * Multivariable-adjusted odds ratios (OR: female vs. male), 95% confidence intervals (95%CI) and p- values from binary logistic regression. Discussion Main findings of our study include a strong positive association of female gender with a lower socioeconomic status among tuberculosis patients diagnosed in Albania during mid-2012 to mid-2013. In particular, unemployment and poor living conditions were considerably more prevalent among female patients with tuberculosis compared with their male counterparts. Furthermore, a lower access to health care and scarce personal resources for a proper and effective health seeking behaviour were substantially more prevalent among female tuberculosis patients. The finding of a positive association of female sex with a lower socioeconomic status, a lower access to health care and a poor health seeking behaviour may point to a lower degree of case notification rate among females compared to males in Albania. Indeed, our finding pointing to a higher case notification rate of tuberculosis among males compared with the females is generally in line with the abundant global evidence on this matter (3-7). Nonetheless, despite the current evidence obtained in various countries and regions, it is not clear whether these sex-differences reflect a distinctive tuberculosis epidemiology (14), or an under-notification Kurti V, Hafizi H, Kurti B, Marku F, Mema D, Burazeri G. Sex-differences in socioeconomic status and health- seeking behaviour among tuberculosis patients in transitional Albania in 2012-2013 (Original research). SEEJPH 2014, posted: 01 September 2014. DOI 10.12908/SEEJPH-2014-30 7 driven by socio-cultural characteristics and/or access to health care services or health seeking behavior (15,16). Regardless of sex, it has been shown that there is a high possibility of under-notification of tuberculosis cases in low-and-middle income countries due to their limited resources coupled with a weak tuberculosis surveillance system (17,18). In this context, the under-notification may affect mostly females, which are assumed to be more vulnerable in terms of their socioeconomic conditions and health seeking behaviour. Thus, biological explanations aside, it has been argued that there is a link between female under-notification rates in the context of specific cultural factors which play an important role in developing and transitional societies (19), such as the case of Albania and perhaps other former communist countries in the Western Balkans. In any case, given the lack of sufficient information, the World Health Organization stimulates further vigorous research related to determinants of sex-differences in case notification rates of tuberculosis (2). On the other hand, in our study, there was no evidence of sex-differences with regard to the place of residence (urban areas vs. rural areas) of tuberculosis patients. Our analysis may have several limitations. Notwithstanding the fact that we included all new patients with tuberculosis diagnosed during the period June 2012 – June 2013, the possibility of under-recording of tuberculosis cases may affect differentially males and females in Albania. Furthermore, it is reasonable to assume a differential recording of new cases based on the demographic and socioeconomic profiles of the patients with tuberculosis. Also, measurement of socioeconomic characteristics and health seeking behaviour – which was based on interview – may have affected, to some degree, our findings. Therefore, future studies in Albania should more vigorously assess determinants of sex-differences in tuberculosis rates in the overall population. In conclusion, our study provides useful evidence about selected correlates of sex-differences among tuberculosis patients in Albania. Health care providers, policymakers and decision- makers in Albania should be aware of the current sex-differences in socioeconomic characteristics, access to health care and health seeking behaviour among tuberculosis patients in this post-communist society. Future studies in Albania and other transitional countries of the Western Balkans should further explore the main determinants of sex-differences in tuberculosis rates. References 1. Weiss MG, Sommerfeld J, Uplekar MW. Social and cultural dimensions of gender and tuberculosis. Int J Tuberc Lung Dis 2008;12:829-30. 2. Uplekar M, Rangan S, Ogden J. Gender and tuberculosis control: towards a strategy for research and action, WHO/TB/2000.280. Geneva: World Health Organization, 1999. 3. World Health Organization (Regional Office for Europe) and the European Centre for Disease Prevention and Control. 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