Health-Related Quality of Life Deterioration Among Tuberculosis Patients During the COVID-19 Pandemic: a Convergent Mixed-Methods Study of Syndemic Vulnerability in Urban Bangladesh

Abstract Background United Nations Sustainable Development Goal 3 (Target 3.3) calls for ending the tuberculosis (TB) epidemic by 2030; yet TB programmes in low-income settings remain acutely vulnerable to pandemic disruption. During the COVID-19 first wave, TB patients in urban Bangladesh faced a convergence of disease burden, pandemic-related stressors, and poverty-driven resource constraints. Systematic evidence quantifying health-related quality of life (HRQoL) deterioration in this population and identifying its modifiable structural determinants is limited. Methods A convergent parallel mixed-methods study was conducted among 439 TB patients attending 12 Directly Observed Treatment, Short-course (DOTS) clinics across six municipal districts in Dhaka, Bangladesh, between August and September 2020. HRQoL was measured with the EQ-5D-3L and post-traumatic stress with the Impact of Event Scale-Revised (IES-R). Multinomial logistic regression identified factors independently associated with HRQoL deterioration. Concurrently, 36 semi-structured in-depth interviews were analysed using Braun and Clarke's thematic analysis framework. Results Pain or discomfort was reported by 46.5% of participants (95% CI: 41.9–51.1%) and anxiety or depression by 36.9% (95% CI: 32.5–41.5%). On multivariable analysis, anxiety/depression was independently associated with larger household size (adjusted OR = 1.08 per person; 95% CI: 1.03–1.14; p = 0.002), greater distance to the DOTS clinic (adjusted OR = 1.03 per km; 95% CI: 1.01–1.05; p < 0.001), and appointment intervals of ≤ 14 days versus 15–30 days (adjusted OR = 2.86; 95% CI: 1.33–7.14; p = 0.011). Drug-resistant TB was strongly associated with activity limitation (adjusted OR = 27.7; 95% CI: 8.3–92.4). Qualitative analysis identified three themes: stigma intensification through symptom conflation with COVID-19; economic hardship obstructing treatment adherence and nutrition; and perceived inadequacy of government relief for chronically ill populations. Conclusions In this cross-sectional study, HRQoL deterioration among urban TB patients in Bangladesh during the COVID-19 pandemic was significantly associated with modifiable structural factors. These preliminary findings suggest that appointment scheduling optimisation, service decentralisation, nutritional support, and psychosocial services may reduce pandemic-era HRQoL burden. Prospective longitudinal studies are needed to establish causality and inform programme design.