SPATIAL PATTERNS OF TUBERCULOSIS IN THE PUNJAB, 1990-2005 PA.ZX Dissertation ssmij Submitted by: Muhammad Shafqaat Aojum Roll No. H EC-02 June 20tl DEPARTMENT OF GEOGRAPHY UNIVERSITY OF THE PUNJAB, LAHORE Abstract The present research is an attempt to explore the occurrence and clustering of tuberculosis patterns in the Punjab, Pakistan. The Punjab, which is the largest province of Pakistan, is selected to examine the patterns of TB from 1990 to 2005. Higher disease rates are found in big cities in 1990. South Punjab was found severely affected throughout the study period. Kulldorff Spatial Scan Test also identified disease dusters in major cities. Moreover, the diseases clusters have shifted from central and north Punjab to the south Punjab during this period. The disease proportion is found higher in females than males. Low income, larger families, illiteracy, and over crowdedness are found important factors in the disease patterns. The knowledge about the disease such as symptoms, causes and precautions is found very poor in the patients. The analysis of healthcare services revealed that the accessibility, time, and cost are important issues for the poor patients. Inequality in the distribution of healthcare services in various districts of the Punjab province is a major concern which is verified by the use of techniques such as Lorenz curve and Gini index. ii 1 Dedicated to My parents, For everything, forever 1 ACKNOWLEDGEMENT Glorified is ALLAH with all praise due to Him, the Greatest is free from imperfection. I praise to Allah the most gracious, most merciful who blessed me to obtain formal education from school up to PhD level. The writing of this dissertation has been one of the most significant academic challenges 1 ever came across. Without the support, guidance, and patience of the people around me, thisstudy would not have been completed. I would like to express my heart felt thanks towards my research supervisor, Prof, Dr. Abdul Ghaffar, Chairman, Department of Geography, University of the Punjab, who has been a constant source of inspiration at every stage of work. His knowledge, expertise, mentorship, and co-operation were paramount in providing me guidance and help at every stage of this research work, 1 am grateful to Dr Darkhshan Badar and Dr Tehseen from DOTS program, Mr, Farooq Ahmad from HMIS, and all the statistical officers in Health department, Punjab, for providing me data and guidance to carryout this research work. I would also like to thank Prof. Sibqat ullah Tahir, Shoaib Khalid, Mrs. Fariha shoaib, and Omar bin Talib from GCUF for their co¬ operation and help. 1 acknowledge with thanks the services and assistance from Mr. Azhar Rasheed (Librarian} and Husnain in the department library who were always kind and supportive. It is not possible to not to pay my sincere gratitude to my friends Tanveer Zafar, Aftab Karim, Omar Riaz, Qais Ullah, Usman Feroz, and particularly Hafiz irfan for their valuable discussion from time to time on various aspects of my research and career. I can never forget to appreciate my friends in UK Samee, Wasee, Farooq, Bob, Amer jalal, and K, L Sunny for their consistent encouragement and cordial cooperation. Finally, with tremendous love, dignity, and honour, I am indeed grateful to my father, Muhammad Hussain Malik and my loving mother, both of them always inspired me with their hard work and commitment and brought success for me through their prayers, l am also obliged to my brothers, Muhammad Sohail and Muhammad Shahzad; sisters, and other family members for their support and encouragement and especially to cute kids in my family Rohaan iii Farhat, Aaliyan Shahbaz, and Mahad Sohail for making me smile during the tiresome and exhaustive research work. In the end I would like to pay special tribute to Higher Education Commission, Government of Pakistan, for providing financial support which has allowed me to focus on my work to complete my Ph.D. Muhammad Shafqaat Anjum iv DECLARATION [, Muhammad Shafqaat Anjum. hereby declare that this dissertation is my own work and all the sources have been quoted and acknowledged by means of complete references. Mi lhafqaat Anjum v TABLE OF CONTENTS Abstract u Acknowledgement iii Declaration v Table of Contents Vi List of Tables ix List of Figures xi CHAPTER 1 INTRODUCTION 1.1 Introduction i 1.2 Research Background 3 1.3 Aims of the study 4 1 .4 Research Objectives 4 1.5 Study Area 4 1,6 Dissertation Structure 8 CHAPTER 2 DATA SOURCES AND METHODLOGY 2,1 Introduction 9 2.2 Data Collection 9 2.2.1 Primary Data 9 2,2.2 Secondary Data 10 2.3 Methodology 11 2,3.1 Data Analysis and Visualization 11 2.3.2 Standardized Morbidity and Mortality Ratio 12 2.3.3 Disease Sex Ratio 13 2.3.4 Disease Clustering 14 2.3.5 Analysis of Healthcare Facilities 15 2.4 Limitations of Data 16 CHAPTER 3 LITERATURE REVIEW 3.1 Medical Geography 19 3.2 Development of Medical Geography 22 3.3 Medical Geography and Geographic Information System 28 3.4 Disease Mapping 30 vi 3.5 Disease Clustering 31 3.6 Ecological Analysis 33 3.7 Analysis of Healthcare Facilities 34 3.8 Literature Review with special reference to Tuberculosis 35 CHAPTER 4 TUBERCULOSIS AND ITS DISTRIBUTION IN THE WORLD 4.1 Tuberculosis 40 4.2 Transmission of Infection 42 4.3 Etiology 43 4.4 Patterns of Tuberculosis Distribution in the World 43 4.5 Disease situation in Pakistan 47 4.6 Role of World Health Organization to combat disease 48 4,7 Directly Observed Treatment Short Course (DOTS) 49 4.8 Summary 50 CHAPTER 5 SPATIAL PATTERNS OF TUBERCULOSIS IN THE PUNJAB 5.1 Introduction 51 5.2 Spatial Patterns of Tuberculosis in the Punjab in 1990 52 5.3 Spatial Patterns of Tuberculosis in the Punjab in 1995 58 5.4 Spatial Patterns of Tuberculosis in the Punjab in 2000 63 5.5 Spatial Patterns of Tuberculosis in the Punjab in 2005 68 5.6 Changes in SMRs from 1990 to 2005 in the Punjab 75 5.7 Smear Positive TB cases 78 5.8 Mortality among TB Patients 83 5.9 TB and Gender 88 5.10 Targets and achievements in the Punjab against TB 94 5.11 Disease Clustering 96 5.11.1 Identification of Disease clusters in the Punjab from 1990 to 2005 97 5.12 Summary 113 CHAPTER 6 ANALYSIS OF RISK FACTORS AND HEALTHCARE FACILITIES 6.1 Introduction 114 6.2 Demographic and Socio-economic conditions of TB Patients 115 vii 6.2.1 Demographic Characteristics of TB Patients 115 6.2.2 TB and illiteracy 119 6.2.3 Economic Conditions ofTB Patients in the Punjab 120 6.2.4 Tuberculosis and Household Income 124 6.2.5 Tuberculosis and Smoking 127 6.2.6 TB Patients and the number of family member Infected 127 6,2.7 Knowledge about Symptoms, Precautions, and Duration of Treatment 127 6.2,8 Tuberculosis and Diet 131 6,2.9 Duration of Treatment and Patient’s satisfaction and trust 131 6.2.10 Drug Intake Missed 131 62.1 1 Tuberculosis and awareness campaign by NTP 132 6.3 Analysis of Healthcare Facilities 132 6.3.1 Healthcare service centers in the Punjab for TB Patients 133 6.3.2 Spatial Distribution of Healthcare services in the Punjab 134 6.3.3 Efficiency and Effectiveness of Healthcare services 143 6.3.4 Accessibility to Health services 149 6.3.5 Spatial Distribution and Inequalities in Health servicesl55 6.3.6 Lorenz Curve and Gini Index 157 6.4 Summary 168 CHAPTER 7 SUMMARY AND CONCLUSION 7.1 Summary and Conclusion 169 7.2 Suggestions 174 7.3 Further Research 175 REFERENCES 177 APPENDICES 195 A. Questionnaire for TB Patients 196 B. Questionnaire for Healthcare Professionals 199 Yin LIST OF TABLES Tabic Title Page 4.1 Estimated TB burden in 22 countries with highest TB burden in the world 45 5.1 Tuberculosis cases and SMR in the Punjab, 1990 54 5.2 Tuberculosis cases and SMR in the Punjab, 1995 59 5.3 Tuberculosis cases and SMR in the Punjab, 2000 64 5.4 Total Number of Tuberculosis Cases{All Forms) Notified in Punjab 2005 70 5.5 Tuberculosis cases and SMR in the Punjab, 2005 71 5.6 A Comparison of SMRs in the Punjab, from 1990 to 2005 76 5.7 Proportion of Smear Positive cases among total patients 80 5.8 Total deaths among TB patients and Standardized Mortality Ratio 85 5.9 TB and Gender differences in the Punjab in 2005 89 6.1 Age groups of TB patients in the Punjab 115 6,2 Age and Sex Composition and Family Size of TB Patients in the Districts of the Punjab 118 6.3 Monthly Household income of TB patients in the Punjab 125 6.4 Diagnostic and Treatment centers for TB Patients in the Punjab 135 6.5 Number of outdoor doctors and patients at health care centers in the Punjab 143 6.6 Ranking the funds and facilities of DOTS program by Healthcare professionals 144 6.7 Dissatisfactionofhealthcare professionals regarding treatment regimen recommended by DOTS Program at healthcare centers in the Punjab 147 6.8 Travel time taken by the tuberculosis patients for one way trip to access to health care centers in the Punjab 151 6.9 Cost per visit for the tuberculosis patients to access to health care centers in the Punjab 154 6.10 Distributionand inequality of health facilities in the Punjab 156 6.11 Cumulative Proportions of Population and Healthcare Facilities in the Punjab 2005 159 6.12 Cumulative Proportions of TB Cases and Healthcare Facilities in the Punjab 2005 162 ix 6.13 Gint Index of the Inequality in Total Population and Health Services in the Punjab 165 6.14 Gini Index of the Inequality in TB Cases and Health Services in the Punjab167 x LIST OF FIGURES Figure Title Page Figure 1.1: Study Area: Punjab province in Pakistan 06 Figure 1.2: Map showing districts in the Punjab province 07 Figure 4,1: Estimated global prevalence, mortality and incidence