Determinants of health-related quality of life in drug-susceptible tuberculosis patients in Ghana: a prospective observational study

Abstract

Background:

Tuberculosis (TB) affects patients' quality of life due to symptoms and social stigma, especially in low-income settings like Ghana. However, data on factors influencing health-related quality of life (HRQOL) in such environments are limited. Identifying these factors is essential for improving treatment outcomes through holistic care.

Objective:

This study determined the impact of sociodemographic and clinical factors on HRQOL at treatment initiation, and monitored changes until the end of treatment.

Design:

Prospective observational study.

Methods:

A cohort of 378 newly diagnosed patients with drug-susceptible TB (mean age: 45.3 ± 15.1 years) was followed across eight hospitals in the Ashanti and Eastern regions of Ghana. Patients received first-line antitubercular treatment, and HRQOL was assessed at baseline, month 2, and month 6 using an interviewer-administered SF-12v2 questionnaire. Associations between HRQOL and sociodemographic or clinical factors were examined using Chi-square or Fisher’s exact tests, while logistic regression was used to estimate crude and adjusted odds ratios (p < 0.05).

Results:

At baseline, 78.8% of participants had impaired physical HRQOL, and 25.7% were at risk of depression. At treatment completion, physical HRQOL impairment remained high (59.5%), with 15.0% still at risk of depression. Only 44.7% showed clinically significant improvement in physical HRQOL, while 39.8% improved in mental HRQOL. Employment, HIV-positive status, and alcohol use were associated with poorer mental HRQOL. Extrapulmonary TB patients demonstrated better physical HRQOL at both the beginning and end of treatment but exhibited poorer mental HRQOL at treatment completion. Widowed participants improved mentally despite poorer baseline health, while married individuals had better physical HRQOL. Higher education correlated with better baseline mental health but lower odds of significant HRQOL improvement.

Conclusion:

Sociodemographic and clinical factors significantly influenced HRQOL in drug-susceptible TB patients after 6 months of treatment. These findings underscore the importance of targeted mental health support during and after treatment to improve patient well-being.

Plain language summary

Factors influencing quality of life in Ghanaian tuberculosis patients and changes during treatment

Tuberculosis (TB) not only causes physical illness but also affects patients' overall well-being, especially in low-income settings like Ghana. This study aimed to understand how TB impacts health-related quality of life (HRQOL) and what factors influence recovery. Researchers followed 378 newly diagnosed TB patients from eight hospitals in Ghana. They assessed their quality of life at the start of treatment, after two months, and at the end of treatment (six months) using a questionnaire. The questionnaire was self-administered for participants who could read and write English, and interviewer-administered for those who could not. The findings showed that most patients had poor physical health at the start of treatment, and many were at risk of depression. Although some improvement was seen by the end of treatment, nearly 60% still had physical health challenges, and 15% remained at risk of depression. Patients with HIV, those who consumed alcohol, and those with jobs requiring high physical or mental effort had worse mental health outcomes. Interestingly, patients with TB outside the lungs (extrapulmonary TB) had better physical health but did not experience as much mental health improvement. Married individuals had better physical health, while widowed patients showed mental health improvement despite poor initial health. Higher education was linked to better mental health at the start but a lower likelihood of overall HRQOL improvement. These results highlight the need for targeted support to help TB patients recover both physically and mentally, ensuring better long-term well-being.

Keywords

Introduction

Tuberculosis (TB) remains a major global health challenge and, after being temporarily surpassed by COVID-19 in 2021 and 2022, returned as the leading cause of death from an infectious disease in 2023.¹ An estimated 10.8 million people worldwide developed TB that year, resulting in 1.25 million deaths, including 161,000 among individuals living with HIV.² In Ghana, over 19,000 new TB cases were recorded in 2023—a 15% increase from cases detected in 2022—accompanied by a mortality rate of 6.1%.³

Beyond its physical toll, TB significantly affects health-related quality of life (HRQOL), a multi-dimensional measure encompassing physical, psychological, and social well-being.⁴ Symptoms, such as fatigue, weight loss, and appetite loss, impair daily activities and productivity.⁵ Moreover, social stigma and fear further compromise the well-being of patients, leading to anxiety, isolation, and poor adherence to treatment.⁶

HRQOL assessments offer insights into how TB and its treatment impact patients’ lives, guiding healthcare providers in developing comprehensive care strategies that enhance treatment adherence and patient confidence.⁷ Studies consistently show that TB negatively affects physical, mental, social, and economic well-being, but successful treatment improves HRQOL over time.^8–10 Globally and in Africa, post-TB lung disease (PTLD) leads to long-term physical impairments, while depression, anxiety, and stigma exacerbate mental health struggles.^10,11 Socially, TB-related stigma affects relationships, employment opportunities, and economic stability.^12–15 In African settings, TB patients often endure more severe symptoms, complications such as lung scarring, and co-infections like HIV, which further worsen health outcomes due to delays in diagnosis.¹⁶ Cultural and gender-related dynamics also play a crucial role, with women facing greater stigma and social exclusion.¹⁶ Despite the growing interest in HRQOL research among TB patients, studies in high-burden African settings, such as Ghana, remain scarce, limiting comparisons with global trends. Most existing studies^6,17 in Ghana use cross-sectional designs, which do not capture how HRQOL evolves over the course of TB treatment or the key factors influencing these changes. Understanding these determinants is essential for evidence-based policymaking that enhances patient-centered TB care.

To bridge this gap, this study aimed to investigate the effects of tuberculosis and its treatment on the HRQOL among TB patients in Ghana, as well as to identify the key determinants influencing HRQOL. By comparing these findings with regional and global trends, the study provides valuable insights to guide healthcare interventions and improve TB management in resource-limited settings.

Materials and methods

Study design and participants

This prospective observational study enrolled a fixed cohort of 378 newly diagnosed, drug-susceptible TB patients who met the inclusion criteria and were prescribed first-line anti-TB medications (rifampicin, isoniazid, ethambutol, and pyrazinamide). The study was conducted from January 10, 2021 to December 15, 2021.

Sociodemographic and clinical data were collected using a structured questionnaire developed based on the study objectives. The SF-12v2 instrument was used to assess participants’ HRQOL. The questionnaire was pretested in two hospitals not included in the main study to evaluate clarity, relevance, cultural appropriateness, and completion time. Feedback from the pretest informed revisions aimed at improving question flow and eliminating ambiguity. Data were collected at baseline, with follow-up assessments conducted at the end of the intensive phase (month 2) and at treatment completion (month 6).

This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Supplemental Table 1).¹⁸

Inclusion and exclusion criteria

The study included adults aged 18 years or older who were newly diagnosed with TB through sputum smear microscopy and were willing to initiate first-line anti-TB treatment. Informed consent was obtained from all participants either by signature or thumbprint.

The study excluded individuals who had previously received TB treatment or were diagnosed with drug-resistant TB. Drug susceptibility was confirmed using GeneXpert, following standard tuberculosis diagnostic protocols in Ghana.

Sample size estimation

The sample size for this study was determined using the formula:¹⁹

n = [{Z^{2}}_{α / 2} p (1 - p)] / d^{2}

where

n = Required sample size

Z_α/2 = Critical value of the standard normal distribution for a 95% confidence level (1.96)

p = Estimated proportion of TB patients with poor HRQOL, set at 0.67⁷

1 − p = Proportion of TB patients with good HRQOL (0.33)⁷

d = Desired margin of error, set at 0.05

Using these parameters, the calculated sample size was approximately 340 participants. To account for potential attrition, a 10% adjustment was applied, resulting in a final sample size of 378.

Study sites

This study was conducted at eight healthcare facilities across two regions in Ghana: the Ashanti and Eastern regions. In each region, three primary hospitals and one secondary referral hospital were selected. These hospitals were chosen based on their high TB case burden, as they recorded the highest number of TB cases in their respective regions in the year preceding the study.

In 2020, Ghana reported a total of 12,544 TB cases. The Eastern and Ashanti regions accounted for 1428 (11.4%) and 2118 (16.9%) of these cases, respectively.²⁰ Along with Greater Accra, these regions are among the most populous in Ghana and consistently rank among the top three regions with the highest TB case notifications.^20,21

Data collection tool

The SF-12v2 survey questionnaire consists of 12 questions designed to assess function and well-being from the patient’s perspective. It is a validated and widely used tool for evaluating quality of life in individuals aged 18 years and older across various chronic disease conditions.^22–24

The SF-12v2 provides scores across eight health domains, categorized into physical and mental health components. The physical health domains include General Health, Physical Functioning, Role-Physical, and Bodily Pain, while the mental health domains comprise Vitality, Mental Health, Social Functioning, and Role Emotional. For this study, the physical component summary (PCS-12) and mental component summary (MCS-12) scores were used for comparative analysis, as they provide a clearer representation of HRQOL than the eight individual domains.²⁵

The SF-12v2 was selected for HRQOL assessment in this study due to its practicality, reliability, and cost-effectiveness. Although not TB-specific, it is a widely validated tool that has been used to evaluate HRQOL in patients with drug-susceptible TB.^26,27 Its brevity, comprehensive coverage of physical and mental health domains, and adaptability make it particularly suitable for resource-limited, high-burden settings such as Ghana.²⁷

While the SF-12v2 has not yet been culturally validated for the Ghanaian population, it has previously been used to assess HRQOL among diabetes patients in Ghana.²² Its application in this study provides valuable baseline data on HRQOL among TB patients. Future research should prioritize adapting and validating the tool to enhance its cultural relevance and better capture context-specific nuances in HRQOL assessment.

Scoring of the tool

The PCS-12 score was calculated by multiplying each survey item by its corresponding physical regression weight and summing the results of the 35 weighted products. Similarly, the MCS-12 score was computed using mental regression weights. If any survey item was left unanswered, the SF-12 summary scores were marked as missing, and the participant’s data were excluded from the analysis. The summary scores were then converted to norm-based scores by adding a constant to the sum, yielding component scores ranging from 0 to 100, with higher scores indicating better quality of life.

A change of ⩾3 points in PCS and MCS scores during treatment was considered a “minimal clinically important difference (MCID).” Participants with a PCS-12 score below 45 were classified as experiencing physical health impairment, while those with an MCS-12 score below 42 were considered “at risk of depression.”²⁵ Therefore, a good physical HRQOL was defined as a PCS-12 score of ⩾45, whereas a score below 45 indicated poor physical HRQOL. Similarly, an MCS-12 score above 42 was classified as good mental HRQOL, while a score of ⩽42 represented poor mental HRQOL.

Statistical analysis

The dataset was initially examined for inconsistencies, duplicates, and outliers using Excel 2016. Missing data for HRQOL estimates were identified through summary statistics and visualization tools. Participant attrition was 11.4% at the first follow-up and 12.2% at the second follow-up due to withdrawal, death, or loss to follow-up.

Data analysis was performed using SPSS version 21 (IBM Corp., Armonk, NY, USA) and STATA version 17 (StataCorp LLC, College Station, TX, USA). Categorical variables were summarized as frequencies and percentages, while continuous variables were reported as mean ± standard deviation (SD) for normally distributed data or median with interquartile range (IQR) for non-normally distributed data. Comparisons of HRQOL component scores across participant characteristics were conducted using independent sample t-tests or analysis of variance (ANOVA) for normally distributed variables, and Mann–Whitney U or Kruskal–Wallis H tests for non-normally distributed variables.

Associations between good mental and physical HRQOL, as well as the attainment of MCID in these domains, and participants’ sociodemographic and clinical characteristics, were evaluated using Chi-squared or Fisher’s exact tests. Logistic regression analysis was performed to assess the strength of these associations, with results reported as crude odds ratios (CORs) and adjusted odds ratios (AORs) to account for potential confounders. A p-value of < 0.05 was considered statistically significant.

Results

Among the 378 participants, the majority were male (67.2%), married (44.2%), and employed (75%), with a mean age of 45.3 years (±15.1). As shown in Table 1, 12.9% had no formal education, 6.1% had extrapulmonary TB (EPTB), 6.4% were smokers, 25.4% consumed alcohol, and 25.7% were living with HIV.

Table 1.

Sociodemographic and clinical characteristics of study participants.

Characteristic	Number of participants (N = 378)	Percentage (%)
Age (years)
18–25	26	6.9
26–35	84	22.2
36–45	90	23.8
46–55	90	23.8
56–65	49	13.0
⩾66	39	10.3
Sex
Male	254	67.2
Female	124	32.8
Marital status
Married	167	44.2
Single	127	33.6
Divorced	41	10.9
Widowed	43	11.3
Employment status
Employed	289	76.5
Unemployed	89	23.5
Educational level
Basic	230	60.9
Secondary	70	18.5
Tertiary	29	7.7
Illiterate	49	12.9
Site of TB infection
Pulmonary TB	350	92.6
Extrapulmonary TB	23	6.1
Both	5	1.3
Smoking status
Smoker	24	6.4
Non-smoker	354	93.6
Alcohol use
Yes	96	25.4
No	282	74.6
HIV status
HIV positive	97	25.7
HIV negative	275	72.8
HIV status unknown	6	1.5

HIV, Human immunodeficiency virus; TB, Tuberculosis.

All participants either self-completed the baseline SF-12v2 questionnaire or were assisted by a research assistant. However, response rates declined over time due to treatment default, death, or withdrawal, with 88.6% (n = 335) responding at the end of the intensive phase and 77.8% (n = 294) completing it by the end of treatment.

Changes in HRQOL over the treatment period

At baseline, 78.8% of participants had impaired physical HRQOL, and 25.7% were at risk of depression. By the end of treatment, physical HRQOL impairment remained high at 59.5%, and 15.0% continued to be at risk of depression.

The mean PCS score improved from 40.2 ± 6.4 at baseline to 44.9 ± 4.4 by the end of treatment, representing an average increase of 4.7 points, which met the MCID threshold (Table 2). In contrast, the mean MCS score showed only a modest increase from 44.5 ± 5.3 at baseline to 46.3 ± 3.7 at treatment completion, with a mean change of 1.8 points, falling below the MCID threshold. Overall, 44.7% of participants achieved MCID for physical HRQOL, while 39.8% met the MCID criteria for mental HRQOL.

Table 2.

Changes in physical and mental health summary scores among tuberculosis patients in Ghana over the course of treatment.

Summary scores	Baseline mean (SD)	End of intensive phasemean (SD)	End-of-treatment mean (SD)	Mean change
Physical Component Summary Score	40.2 (6.4)	43.3 (4.8)	44.9 (4.4)	4.7
Mental Component Summary Score	44.5 (5.3)	45.3 (3.3)	46.3 (3.7)	1.8

Mean change in scores represents the difference between baseline and end-of-treatment scores. Higher scores reflect better health-related quality of life.

SD, standard deviation.

Factors influencing HRQOL outcomes

Employment status was a significant predictor of mental HRQOL outcomes. Employed participants had lower odds of achieving good mental HRQOL at the end of treatment (AOR = 0.19, 95% CI: 0.05–0.67, p = 0.010) and reaching MCID for mental health (AOR = 0.44, 95% CI: 0.24–0.81, p = 0.009) compared to unemployed participants (Table 3).

Table 3.

Factors associated with good health-related quality of life at baseline and end of treatment in tuberculosis patients in Ghana.

Characteristics	Baseline mental health		End-of-treatment mental health		Attaining mental health MCID		Baseline physical health		End-of-treatment physical health		Attaining physical health MCID
Characteristics	COR(95% CI)	AOR (95% CI)	COR(95% CI)	AOR (95% CI)	COR(95% CI)	AOR (95% CI)	COR(95% CI)	AOR (95% CI)	COR(95% CI)	AOR (95% CI)	COR(95% CI)	AOR (95% CI)
Employment status	p = 0.085	–	p = 0.047	p = 0.01	p = 0.009	p = 0.009	p = 0.699	–	p = 0.712	–	p = 0.503	–
Unemployed (ref)	1	–	1	1	1	1	1	–	1	–	1	–
Employed	0.61, (0.34–1.09)	–	0.41, (0.15–1.08)	0.19, (0.05–0.67)	0.48, (0.27–0.83)	0.44, (0.24–0.81)	1.17, (0.52–2.66)	–	1.14, (0.56–2.31)	–	1.21, (0.69–2.10)	–
HIV status	p < 0.001	p < 0.001	p = 0.453	–	p = 0.289	–	p = 0.923	–	p = 0.661	–	p = 0.084	–
Negative (ref)	1	1	1	–	1	–	1	–	1	–	1	–
Positive	0.35, (0.20–0.57)	0.39, (0.24–0.66)	1.36, (0.60–3.09)	–	1.35, (0.78–2.35)	–	1.04, (0.48–2.23)	–	0.86, (0.51–1.47)	–	1.65, (0.93–2.93)	–
Alcohol use	p = 0.002	p = 0.002	p = 0.687	–	p = 0.278	–	p = 0.891	–	p = 0.826	–	p = 0.593	–
No (ref)	1	1	1	–	1	–	1	–	1	–	1	–
Yes	0.44, (0.27–0.73)	0.43, (0.25–0.74)	0.86, (0.42–1.77)	–	1.35, (0.79–2.30)	–	1.05, (0.49–2.26)	–	0.93, (0.48–1.81)	–	0.86, (0.51–1.47)	–
Site of TB Infection	p = 0.565	–	p < 0.001	p < 0.001	p = 0.002	p = 0.032	p = 0.004	–	p < 0.001	p < 0.001	p = 0.109	–
Pulmonary (ref)	1	–	1	1	1	1	1	–	1	1	1	–
Extrapulmonary	1.31, (0.51–3.33)	–	0.15, (0.07–0.35)	0.13, (0.05–0.34)	0.23, (0.08–0.67)	0.30, (0.10–0.90)	4.27, (1.73–10.51)	–	11.93, (5.04–28.23)	13.12, (5.12–33.61)	1.96, (0.83–4.62)	–
Marital status	p = 0.017	p = 0.02	p = 0.052	p = 0.009	p = 0.098	–	p = 0.896	–	p = 0.01	p = 0.034	p = 0.875	–
Single (ref)	1	1	1	1	1	–	1	–	1	1	1	–
Married	0.62, (0.35–1.09)	0.68, (0.38–1.22)	1.85, (0.92–3.71)	3.93, (1.64–9.40)	1.04, (0.60–1.80)	–	1.06, (0.50–2.25)	–	0.79, (0.43–1.47)	0.47, (0.23–0.96)	0.97, (0.57–1.65)	–
Divorced	0.48, (0.21–1.06)	0.65, (0.28–1.48)	3.14, (0.88–11.22)	3.70, (0.97–9.40)	2.04, (0.94–4.43)	–	0.95, (0.29–3.09)	–	0.17, (0.04–0.74)	0.19, (0.04–0.86)	1.21, (0.55–2.63)	–
Widowed	0.31, (0.14–0.65)	0.28, (0.13–0.62)	4.29, (0.95–19.36)	3.07, (0.65–14.47)	2.07, (0.92–4.65)	–	0.66, (0.18–2.43)	–	0.29, (0.08–1.03)	0.34, (0.09–1.21)	1.28, (0.56–2.90)	–
Level of Education	p = 0.029	–	p = 0.023	p = 0.023	p = 0.006	p = 0.011	p = 0.180	–	p = 0.355	–	p = 0.355	–
Illiterate (ref)	1	–	1	1	1	1	1	–	1	–	1	–
Basic	1.18, (0.61–2.29)	–	0.32, (0.07–1.41)	0.43, (0.09–2.00)	0.58, (0.29–1.16)	0.70, (0.34–1.44)	3.13, (0.72–13.61)	–	1.60, (0.58–4.41)	–	0.67, (0.32–1.39)	–
Secondary	2.60, (1.08–6.26)	–	0.32, (0.06–1.59)	0.54, (0.10–2.88)	0.26, (0.11–0.63)	0.32, (0.13–0.78)	3.47, (0.72–16.81)	–	2.55, (0.84–7.74)	–	0.70, (0.30–1.64)	–
Tertiary	3.03, (0.90–10.19)	–	0.11, (0.02–0.55)	0.1, (0.02–0.58)	0.27, (0.09–0.79)	0.24, (0.08–0.72)	–	–	1.94, (0.53–7.17)	–	0.40, (0.15–1.10)	–
WHO HIV stage	p = 0.333	–	p = 0.018	–	p = 0.354	–	p = 0.785	–	p = 0.843		p = 0.310	–
Stage 1 (ref)	1	–	1	–	1	–	1	–	1	–	1	–
Stage 2	0.41, (0.10–1.21)	–	0.1, (0.16–0.63)	–	0.24, (0.03–2.19)	–	1.26, (0.24–6.67)	–	0.80, (0.08–7.56)	–	0.41, (0.07–2.25)	–
Stage 3	0.39, (0.06–2.49)	–	–	–	–	–	2.36, (0.23–24.12)	–	–	–	–	–
Stage 4	0.59, (0.04–9.77)	–	–	–	1.2, (0.07–20.18)	–	–	–	–	–	-	–

Interpretation Guidance: Odds ratios greater than 1 indicate a higher likelihood, while those less than 1 indicate a lower likelihood of achieving the specified health-related quality of life outcomes compared to the reference group. Level of Education was dropped from the final model of baseline mental health because it did not nest with the other significant variables. Bolded p-values indicate statistical significance at p < 0.05.

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; HIV, human immunodeficiency virus; MCID, minimal clinically important difference; TB, Tuberculosis; WHO, World Health Organization.

HIV status significantly influenced baseline mental health, with those living with HIV being less likely to have good mental HRQOL (AOR = 0.39, 95% CI: 0.24–0.66, p < 0.001). However, it did not significantly impact HRQOL outcomes at the end of treatment or the likelihood of achieving MCID.

Alcohol consumption was associated with poorer baseline mental health, as alcohol users had lower odds of good mental HRQOL (AOR = 0.43, 95% CI: 0.25–0.74, p = 0.002), although this effect was not significant at treatment completion.

The site of TB infection also played a role in HRQOL outcomes. Patients with EPTB had significantly better baseline physical HRQOL (COR = 4.27, 95% CI: 1.74–10.51, p = 0.004) and showed greater improvement by the end of treatment (AOR = 13.12, 95% CI: 5.12–33.61, p < 0.001). However, they were less likely to achieve MCID for mental health (AOR = 0.13, 95% CI: 0.05–0.34, p < 0.001).

Marital status also influenced HRQOL outcomes. Widowed participants had poorer baseline mental HRQOL (AOR = 0.28, 95% CI: 0.13–0.62, p = 0.002) but were more likely to achieve good mental HRQOL at the end of treatment (AOR = 3.07, 95% CI: 0.65–14.47, p = 0.009). Meanwhile, married participants had better physical HRQOL at treatment completion (AOR = 3.93, 95% CI: 1.64–9.40, p = 0.009), though marital status did not significantly affect MCID achievement.

Education level was another determinant of HRQOL. Higher education was associated with better baseline mental HRQOL (COR = 3.03, 95% CI: 0.90–10.19, p = 0.029) but was linked to lower odds of achieving MCID for both mental (AOR = 0.10, 95% CI: 0.02–0.58, p = 0.023) and physical HRQOL (AOR = 0.24, 95% CI: 0.08–0.72, p = 0.011) compared to participants with no formal education.

Discussion

This study underscores the profound impact of TB on HRQOL, affecting both physical and mental well-being. Although treatment resulted in some improvement, a substantial proportion of patients—55.3% in physical HRQOL and 60.2% in mental HRQOL—did not achieve clinically meaningful improvements by the end of therapy. These findings highlight the persistent burden of TB even after treatment completion.

At baseline, the PCS score (40.2 ± 6.4) was higher than reported in the UK²⁸ but lower than in Malaysia.⁷ Similarly, the baseline MCS score (44.5 ± 5.3) exceeded values observed in both countries. By the second month of treatment, the PCS score increased to 43.3 ± 4.8, surpassing UK values but remaining below Malaysian levels, while the MCS score (45.3 ± 3.3) slightly exceeded that of Malaysia but was still lower than in the United Kingdom. By treatment completion, the PCS score (44.9 ± 4.4) remained slightly below Malaysia’s, whereas the MCS score (46.3 ± 3.7) was comparable. These findings suggest that while TB treatment leads to modest HRQOL improvements, recovery trajectories vary across populations, emphasizing the role of contextual factors in shaping outcomes.

The persistent deficits in physical HRQOL may be attributed to pulmonary complications such as fibrosis, airway obstruction, and chronic respiratory symptoms—including dyspnea and fatigue—resulting from delayed presentation to the hospital and late diagnosis.^13,29 Some patients may have developed PTLD, further compromising physical function.^14,29 Additionally, factors such as malnutrition, prolonged illness, medication side effects (e.g., neuropathy and joint pain), and comorbid conditions such as HIV/AIDS and diabetes likely contributed to poor physical outcomes.^30–32 These findings underscore the need for long-term rehabilitation and supportive care beyond the standard treatment duration.

The site of TB infection significantly influenced HRQOL outcomes. Patients with extrapulmonary TB (EPTB) consistently exhibited better physical HRQOL than those with pulmonary TB (PTB), likely due to a lower bacterial burden and reduced pulmonary damage. However, EPTB patients experienced poorer mental HRQOL, mirroring findings from Nigeria³³ and Ghana,⁶ where EPTB was associated with greater psychological distress. EPTB often necessitates prolonged treatment and hospitalization, contributing to emotional stress and heightened symptom burden.^34,35 This suggests that while PTB primarily affects physical health, EPTB patients face more pronounced emotional and social challenges.^10,11,36

Marital status emerged as a critical determinant of physical HRQOL. Divorced participants were significantly less likely to achieve good physical HRQOL, consistent with findings from Pakistan.⁵ The adverse impact of divorce on HRQOL may stem from heightened emotional distress, social isolation, and financial strain, all of which can exacerbate both physical and mental health challenges.⁵ The loss of social support may also contribute to reduced treatment adherence, poorer nutritional status, and increased stigma, further impeding recovery.³⁷ These findings highlight the importance of psychosocial support interventions to improve HRQOL among divorced TB patients.

Despite mental HRQOL being generally better than physical HRQOL throughout treatment, mean MCS scores remained below the population norm. At treatment initiation, 25% of participants were at risk of depression, a figure that remained significant at 15.0% by treatment completion. While this percentage was lower than the 67% reported in Malaysia at baseline and the 23.5% at the end of treatment,⁷ it still indicates a substantial burden of psychological distress.

Several factors influenced mental HRQOL. HIV infection and alcohol use were significant predictors of lower MCS scores at baseline. Alcohol use disrupts neurotransmitter balance, weakens treatment adherence, and promotes social isolation, exacerbating mental health deterioration. It also impairs immune function, increases relapse risks, and interferes with TB medication metabolism.^38,39 Counseling interventions aimed at reducing alcohol consumption may enhance HRQOL and overall cardiovascular health.⁴⁰ Conversely, higher education levels were associated with better mental HRQOL at baseline, in line with findings from Yemen⁴¹ and Pakistan,¹⁰ potentially due to increased health literacy, improved coping strategies, and better healthcare access.⁴²

However, at treatment completion, tertiary education, EPTB infection, and WHO HIV Stage 2 were associated with poorer mental HRQOL. These findings suggest that EPTB-related psychological distress, heightened illness awareness among highly educated individuals, and the mental health burden of HIV contribute to reduced HRQOL. HIV-related neuroinflammation, stigma, and cognitive impairment may elevate the risk of depression and anxiety.^43,44 In addition, widowhood was associated with greater mental distress, potentially due to grief, social isolation, and financial difficulties.⁴⁵ These findings reinforce the need for integrating mental health services into TB care to address psychological distress and improve overall HRQOL.

The mean change in PCS score (4.7) at treatment completion, which met the MCID threshold, was comparable to the 4.1 observed in Malaysia.⁷ However, the mean change in MCS score (1.8) was substantially lower than the 6.9 reported in Malaysia and did not reach the MCID threshold. Achievement of MCID in HRQOL was influenced by sociodemographic and clinical factors. WHO HIV Stage 2 patients were less likely to achieve MCID in physical HRQOL, underscoring the compounded challenges of TB/HIV co-infection.²⁶ Employment, EPTB infection, and higher education levels were associated with lower odds of achieving MCID in mental HRQOL, reinforcing the trend of persistently lower MCS scores in these groups.

The association between higher education and lower HRQOL improvement is particularly noteworthy. While education is generally linked to better health outcomes,^26,41 highly educated individuals may have heightened awareness of post-treatment symptoms and complications, leading to dissatisfaction with recovery.⁴⁶ Professional responsibilities and economic pressures may further contribute to stress and hinder full psychological recovery. Moreover, TB-related stigma may be more pronounced among educated individuals, affecting mental well-being and professional reintegration.¹⁴ These findings suggest the need for workplace reintegration programs and psychological support for TB patients returning to demanding professional roles.

Strengths and limitations

This study makes an important contribution to the limited body of research on TB-related HRQOL in low- and middle-income countries by employing longitudinal data to assess changes over the course of treatment. The inclusion of both physical and mental HRQOL measures offers a comprehensive perspective on patient well-being beyond traditional clinical outcomes. Nonetheless, the study is subject to certain limitations. Attrition bias may have influenced the representativeness of the findings, and the study did not assess long-term post-treatment outcomes. Furthermore, although the SF-12v2 instrument provided valuable data, it has not been culturally adapted or formally validated for the Ghanaian population due to financial constraints. Its prior use in a Ghanaian study underscores the need for formal validation in this context.

Conclusion

This study highlights the lasting impact of tuberculosis on both physical and mental HRQOL, even after treatment completion. While some improvements occur over time, many patients—especially those with pulmonary TB—experience persistent physical impairments, while extrapulmonary TB patients face greater psychological and social challenges. Key predictors of poor HRQOL include marital status, HIV co-infection, alcohol use, and educational level, reflecting the complex interaction of sociodemographic and clinical factors in influencing HRQOL among TB patients. Notably, higher education, while beneficial for health literacy, may also heighten awareness of disease complications and social stigma, contributing to lower HRQOL scores. These findings underscore the need for targeted interventions such as long-term rehabilitation, psychosocial support, and integrated care models to improve patient well-being. Future research should focus on addressing post-TB complications and enhancing HRQOL beyond microbiological cure.

Supplemental Material

sj-docx-1-tai-10.1177_20499361251343143 – Supplemental material for Determinants of health-related quality of life in drug-susceptible tuberculosis patients in Ghana: a prospective observational study

Supplemental material, sj-docx-1-tai-10.1177_20499361251343143 for Determinants of health-related quality of life in drug-susceptible tuberculosis patients in Ghana: a prospective observational study by Richard Delali Agbeko Djochie, Berko Panyin Anto and Mercy Naa Aduele Opare-Addo in Therapeutic Advances in Infectious Disease

Supplemental Material

sj-docx-2-tai-10.1177_20499361251343143 – Supplemental material for Determinants of health-related quality of life in drug-susceptible tuberculosis patients in Ghana: a prospective observational study

Supplemental material, sj-docx-2-tai-10.1177_20499361251343143 for Determinants of health-related quality of life in drug-susceptible tuberculosis patients in Ghana: a prospective observational study by Richard Delali Agbeko Djochie, Berko Panyin Anto and Mercy Naa Aduele Opare-Addo in Therapeutic Advances in Infectious Disease

Footnotes

Acknowledgements

We extend our sincere gratitude to the managers and staff of the hospitals in the Ashanti and Eastern regions of Ghana for their support and cooperation during the conduct of this study. We are deeply grateful to the tuberculosis patients who participated in this study for their time, trust, and willingness to share their experiences.

Declarations

ORCID iDs

Richard Delali Agbeko Djochie

Mercy Naa Aduele Opare-Addo

Supplemental material

Supplemental material for this article is available online.

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