||When tuberculosis treatment fails: A social behavioural
account of patient adherence.
||AME REV RES DIS 1993, 147, 1311-1320.
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
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.
|KEYWORDS: SOCIAL BEHAVIOUR; CASE HOLDING; DEFAULT;