||Liefooghe R, Suetens C, Meulemans H, Moran MB &
De Muynck A
||A randomised trial of the impact of counselling on
treatment adherence of tuberculosis patients in Sialkot, Pakistan
||INT J TB & LUNG DIS 1999, 3, 1073-1080
In Pakistan, TB is a major health problem and is
perceived as a stigmatised disease. Implementation of DOTS is limited
to only few districts due to poor functioning of primary health
care and inability to strengthen them before DOTS implementation.
Bethania Hospital (BH) in Sialkot town of Punjab province in Pakistan
is the acknowledged centre for treatment of TB patients since 1970.
Still the major problem faced by BH has been poor compliance. Various
alternatives to improve compliance were tried e.g., hospitalization
for initial 6 weeks, introduction of SCC of 8 months, which had
some improvement, but was not appreciable as SCC regimen had 12%
initial defaulter and 34% of these put on treatment did not complete
Keeping in view the social attitude and the health
beliefs of the local people, it was decided to offer intensive counselling
to improve treatment adherence. The objective of the study was to
assess the overall impact of counselling on treatment defaulting
and to identify sub-groups in which counselling was the most effective.
The statistical design was a randomised controlled intervention
trial. A total of 1019 adult TB patients were interviewed and taken
into the study and the control group during full one year of 1995.
Baseline data were obtained through semi-structured interviews by
trained para-medicals of both genders and belonging to the same
socio-economic background. Patients were followed until the end
of treatment. The counselling was given at the start of treatment
and at each subsequent visit for ambulatory patients, or weekly
for hospitalized patients in the study group. The counselling, combined
health education with strategies was aimed to strengthen the self-efficacy.
Control group patients received the usual care. According to treatment
policy, patients scheduled for SCC were advised to accept hospitalisation
for the 2 months of intensive phase of treatment. Ambulatory patients
mainly received a 12-month regimen. Of the 63% of patients who accepted
hospitalisation, only 40% remained hospitalised for the full 2 months.
The outcome measure was treatment default, cure, referral or death.
Results showed that the default rate was 54% in the control and
47% in the intervention group; the default risk ratio was 8.7, implying
a reduction in defaulting of 13%. Intensive counselling has a significant,
although limited, impact on treatment adherence. The impact was
stronger in women, ambulatory patients, re-treatment patients, women
who worked at home, and patients who were not the main providers,
those with poor knowledge of the disease or those with a short treatment
delay. Counselling does not eliminate the need for closely supervised
treatment but it is a useful additional strategy for improving treatment
adherence. In the long run counselling has the potential to reduce
the stigmatisation of TB patients. In countries like Pakistan, where
the implementation of DOT is currently hampered by the absence of
functional health infrastructure at the peripheral level, the combined
strategy of counselling and family based DOT could offer a valid
alternative to the immense and urgent problem of TB control.
|KEY WORDS: COUNSELLING; INTERVENTION; COMPLIANCE; ADHERENCE;