BackgroundThe poor face geographical, socio-cultural and health system barriers in accessing tuberculosis care. These may cause delays to timely diagnosis and treatment resulting in more advanced disease and continued transmission of TB. By addressing barriers and reasons for delay, costs incurred by TB patients can be effectively reduced. A Tool to Estimate Patients' Costs has been developed. It can assist TB control programs in assessing such barriers. This study presents the Tool and results of its pilot in Kenya.MethodsThe Tool was adapted to the local setting, translated into Kiswahili and pretested. Nine public health facilities in two districts in Eastern Province were purposively sampled. Responses gathered from TB patients above 15 years of age with at least one month of treatment completed and signed informed consent were double entered and analyzed. Follow-up interviews with key informants on district and national level were conducted to assess the impact of the pilot and to explore potential interventions.ResultsA total of 208 patients were interviewed in September 2008. TB patients in both districts have a substantial burden of direct (out of pocket; USD 55.8) and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a major cause of increased poverty. Results confirm a 'medical poverty trap' situation in the two districts: expenditures increased while incomes decreased. Subsequently, TB treatment services were decentralized to fifteen more facilities and other health programs were approached for nutritional support of TB patients and sputum sample transport. On the national level, a TB and poverty sub-committee was convened to develop a comprehensive pro-poor approach.ConclusionsThe Tool to Estimate Patients' Costs proved to be a valuable instrument to assess the costs incurred by TB patients, socioeconomic situations, health-seeking behavior patterns, concurrent illnesses such as HIV, and social and gender-related impacts. The Tool helps to identify and tackle bottlenecks in access to TB care, especially for the poor. Reducing delays in diagnosis, decentralization of services, fully integrated TB/HIV care and expansion of health insurance coverage would alleviate patients' economic constraints due to TB.

This study investigated the associations among depression, relationship quality, and demand/withdraw and demand/submit behavior in couples' conflict interactions. Two 10-min conflict interactions were coded for each couple (N = 97) using Structural Analysis of Social Behavior (SASB; Benjamin, 1979a, 1987, 2000a). Depression was assessed categorically (via the presence of depressive disorders) and dimensionally (via symptom reports). Results revealed that relationship quality was negatively associated with demanding behavior, as well as receiving submissive or withdrawing behavior from one's partner. Relationship quality was positively associated with withdrawal. Demanding behavior was positively associated with women's depression symptoms but negatively associated with men's depression symptoms. Sequential analysis revealed couples' behavior was highly stable across time. Initiation of demand/withdraw and demand/submit sequences were negatively associated with partners' relationship adjustment. Female demand/male withdraw was positively associated with men's depression diagnosis. Results underscore the importance of sequential analysis when investigating associations among depression, relationship quality, and couples' interpersonal behavior.

This is an electronic reprint of the original article. This reprint may differ from the original in pagination and typographic detail.

No abstract

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details.