c) Behavioural And Psychological Factors
AU : Wallace Fox
TI : The problem of self-administration of Drugs; with particular reference to pulmonary tuberculosis
SO : TUBERCLE 1958, 39, 269-274
AB :

For patients given treatment for self administration at home, there is inherent problem of regularity of intake of drugs particularly if the treatment is long term. It is a common observation that patients with myxoedema, auricular fibrillation, or epilepsy even when their malady is under control are not completely regular. It is just that they take sufficient number of doses of the medicine for successful control of their disease. In leprosy, self administration is rarely relied upon and some form of supervised administration of Diaminodiphenylsulphone (DDS) is devised. This phenomenon is observed even with short term treatment with acute diseases. In 1955, Mohler et al., reported that 32% of 217 patients took less than prescribed doses of one week oral penicillin course for treatment of acute pharyngitis/otitis media. Turning from treatment to prophylaxis, reference may be made to rheumatic fever. WHO expert committee in 1957, stated that unless physician take continuous responsibility, the patient and his family are motivated to take drugs regularly and continuous medical surveillance is done by Public Health Services, the prophylaxis cannot be given successfully. The difficulty in keeping persons who adopt small family norms to observe contraceptive measures is well known. It therefore seems likely from experience in other fields that self administration of drugs may present some problems in TB also.

Experience in Pulmonary TB: Although the effective drug regimen for treatment of TB on mass scale is mandatory, the regularity with which patients will self administer the anti TB drugs for long time is also of fundamental importance. Some amount of information obtained on self administration of anti TB drugs at home from an on going study on “Home Vs Sanitorium treatment” at Tuberculosis Chemotherapy Centre, Madras (Bull WHO 1959, 21, 51-144) is presented here. This will be useful in indicating the problems of self administration of drugs in TB. The regimen used in the study is 12PH (PAS & Isoniazid for 1 year) six to seven cachets (each cachet containing 1.25 gm PAS & 25 mg of Isoniazid) according to body weight. Once a week the patient collects supply of drugs from the centre. They are motivated along with their family about the importance of regularity for the total duration of one year and informed that early disappearance of symptoms may not be considered as cured. Home visits by the field staff are made once a week in the initial 2 months & later on fortnightly basis to collect urine for ferric chloride test for presence of PAS, sputum for culture & sensitivity for Mycobacterium TB (M.tb) and counting of stock of cachets. Some of the visits made are unexpected. The patients are assessed clinically, radiographically and bacteriologically every month.

Preliminary analysis of urine for the presence of PAS was made in a group of 79 patients on home and 81 on sanitorium series. Of the 79 patients on home, 58 patients who completed one year of treatment, 20% gave at least one test negative in the first six months, 14% in the later six months & 9% of the remaining 21 recently admitted patients. In the sanatorium group, 58 of the 81 patients who completed one year of treatment, 4% gave negative results during first six months of treatment and only 0.6% during the second six months. Thus showing the irregularity is high during first six months and the problem of missed treatment is peculiar to the group treated at home, where the patients are not under direct observation. Rregularity by counting cachets is not accurate as the drugs can be sold, given or thrown away; it is best reliable during unexpected visits & can be only complimentary to urine testing. During interviews, reasons for omitting doses were never forthcoming & were obtained by deep probing and suggestions. Thus the questioning indicated the reasons for failure of drug intake as follows: i) Very few patients have minor side effects. ii) Some are unable to satisfy hunger & some attribute-unassociated complaints to the medicine. iii) Few are irregular due to religious reasons. iv) A large group of patients have no explanations, and apparently fail to take their medicine due to forgetfulness or through indolence. In this last group of patients unless the irregularities had been specially looked for, their occurrence would not have been suspected as great majority of them keep up the social side of the relationship with the clinic and attend regularly.

Unfortunately very little is known of the motives, which impel a patient to take medicine and the best way to get him to do so. In essence, in order to make a patient to take medicine regularly morning and night for a year it is necessary to establish a new pattern of behaviour; and this many of the patients find difficult. If the irregularity in self medication is small and does not influence the outcome it does not matter but if the evidence suggest that the irregularity carries serious consequences then i) Find a way to make patient regular in taking their medicine. ii) To alter our out look on the ideal form of home treatment. iii) To study regimen given daily or intermittently under direct observation.