a) Treatment Failure & The Problem of Non Adherence
AU : Sumartojo E
TI : When tuberculosis treatment fails: A social behavioural account of patient adherence.
SO : AME REV RES DIS 1993, 147, 1311-1320.
DT : Per
AB :

The report provides an account of the research on patient adherence as it relates to the treatment and prevention of TB. It summarizes the literature on social and behavioural factors that relate to whether patients take anti-TB medicines and complete treatment and it suggests issues that require the attention of researchers who are interested in behavioural questions relative to TB. Several conclusions about measuring adherence can be drawn. Probably the best approach is to use multiple measures, including some combination of urine assays, pill counts and detailed patient interviews. Careful monitoring of patient behaviour early in the regimen will help predict whether adherence is likely to be a problem. Microelectronic devices in pill boxes or bottle caps have been used for measuring adherence among patients with TB, but their effectiveness has not been established. The use of these devices may be particularly troublesome for some groups such as the elderly, or precluded for those whose life styles might interfere with their use such as the homeless or migrant farm workers.

Carefully designed patient interviews should be tested to determine whether they can be used to predict adherence. Probably the best predictor of adherence is the patient`s previous history of adherence. However, adherence is not a personality trait but a task specific behaviour. For example, someone who misses many doses of anti-TB medication may successfully use prescribed eye drops or follow dietary recommendations. Providers need to monitor adherence to anti-TB medications early in the treatment in order to anticipate future problems and to ask patients about specific adherence tasks. Ongoing monitoring is essential for patients taking medicine for active TB. These patients typically feel well after a few weeks and either may believe that the drugs are no longer necessary or may forget to take medication because there are no longer physical cues of illness. Demographic factors, though easy to measure, do not predict adherence well. Tending to be surrogates for other causal factors, they are not amenable to interventions for behaviour change. Placing emphasis on demographic characteristics may lead to discriminatory practices. Patients with social support networks have been more adherent in some studies and patients who believe in the seriousness of their problems with TB are more likely to be adherent. Additional research on adherence predictors is needed, but it should reflect the complexity of the problem. This research requires a theory based approach which has been essentially missing from studies on adherence and TB. Research also needs to target predictors for specific groups of patients.

There is clear evidence on adherence, culturally influenced beliefs and attitudes about TB and its treatment. Therefore, culturally sensitive, targeted information is needed. A taxonomy of groups and their beliefs would assist in the development of educational materials. Educational interventions should emphasize adherence behaviours rather than general information about TB or treatment. Further research is needed to define the social and behavioural dimensions of effective treatment and control and, creative programming must take advantage of the latest research.