||CHAPTER IV - TREATMENT BEHAVIOUR OF
||Case-holding and treatment failures under a TB clinic
operating rural setting.
|| INDIAN J TB 1990, 37, 145-148.
A retrospective cohort of 996 TB patients, between
Jan. 1986 and Feb. 1987, diagnosed and treated at a rural TB clinic
in 24 Parganas District of West Bengal, was analysed with regard
to case-holding, treatment completion and failure to achieve a successful
result vis-a-vis sputum-positive patients. The overall treatment
completion rate was 67% and sputum-conversion among the bacillary
cases was 57%. The study revealed that the treatment completion
rate in the project area cases, who got home visits and remotivation
in the event of a default in drug collection, was no better than
that of non-project patients who merely got postal reminders. Treatment
compliance rate was significantly better among those below 30 years
of age and females when compared with older and male patients. Other
study results were comparable to those obtained in a DTC TB clinic
in urban conditions.
|KEYWORDS: DEFAULT; CASE HOLDING; INDIA.
||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;
||Rom WN & Garay SM
||Tuberculosis : Adherence to regimens and Directly Observed
||Tuberculosis, Little, Brown & Company, Boston,
1996, p. 927-934
Since chemotherapy first proved efficacious for
TB, a significant number of patients have failed to complete an
adequate course of therapy. An enormous research performed over
the last 40 years has contributed greatly to our understanding of
the complex nature of why patients fail to take their medication
as prescribed. Despite our increased knowledge of such patient behaviours,
modern medical practitioners, to date, have neither the means to
identify in advance all patients who will fail to take their medication,
nor the means to detect all those who are not taking their medication
during the course of their therapy. In the case of a communicable
disease such as TB, the well-being of the patient and the interest
of the public health overlap. Physicians, in general, and public
health officers, in particular, are charged not only with ensuring
that individuals are adequately treated so that they may be cured
of their disease, but health care professionals are legally obligated
to ensure that adequate treatment occurs to protect the public from
the threat of TB.
The authors have deduced six steps to optimize
patient adherence which is termed as Denver Model The
principles of using these steps would maximize the efficiency of
DOT by eliminating as many barriers as possible and by creating
a structure that readily locate the lost patient. They
are: (i) Know the patient: Initial encounters with the patient should
be used to aggressively gather information. The goal of these sessions
should be to identify as many points as possible at which the patient
connects with the community. (ii) Assign a case manager: Each patient
should have one health care professional who is identified as a
specific contact. If at all possible, this contact should have fluency
in the patients first language; if that is not possible, the
contact should arrange for an adequate translator to be present
for sessions with the patient. Ideally, the case worker and patient
will establish a sound and stable therapeutic relationship. (iii)
Establish inducements and enablers: Many patients with TB are afflicted
with numerous social ills in addition to their disease. Homelessness,
hunger, and substance abuse can make TB seem the least of their
worries; thus, adherence to medication assumes a low priority. If
the TB clinic can meet some of the patients other needs, contact
with the clinic assumes a higher priority, and the likelihood of
adherence to therapy is much greater. The use of enablers
has also been advocated. Enablers are services that remove barriers
to the patients participation. For a patient without transportation
an enabler might be a bus token or a taxi voucher; for a mother
it might be child care so that she can come to the clinic. All of
this sounds expensive, but the ultimate total cost of inducements
and enablers is far less than the cost of inpatient care in the
case of the patient who fails these outpatient efforts, not to mention
the cost of caring for the additional cases that will result from
failure to treat. (iv) Be flexible: Every attempt should be made
to accommodate the patients needs and schedule. Whenever possible,
reliable contacts in the community should be identified so the patient
can get medication 24 hours a day. (v) Involve community workers:
Part-time employment of reliable members of the patients community
can prove invaluable. Ideally, this would be an individual who knows
the patient and the patients neighbourhood, someone who could
quickly locate the patient if he/she failed to show for an appointment
and who could determine the reason for the missed appointment as
well as administer the missed dose. (vi) Issue an order of quarantine:
Patients should clearly understand that their adherence to medical
therapy is legally mandated and is offered in lieu of physical quarantine.
The patient should receive an order of quarantine that clearly explains
this and makes clear that failure to present for medication doses
may result in incarceration for the duration of therapy.
Nearly thirty years of experience with the direct
observation of antituberculous chemotherapy in Denver have proven
these to be effective measures. Each case of TB in Denver County
is treated with impartiality. Every patient with TB received DOT
and no exceptions are made.
|KEY WORDS: CASE HOLDING, DOTS, ADHERENCE; USA
||Sophia Vijay, Balasangameshwara VH & Srikantaramu
||Treatment dynamics and profile of tuberculosis patients
under the District Tuberculosis Programme (DTP) A prospective
|| INDIAN J TB 1999, 46, 239-249
A prospective cohort study among new smear positive
pulmonary TB cases initiated on SCC was undertaken in Kolar district
of Karnataka. The objective was to study the treatment outcome and
patient profile of treatment adherent (completed) and non-adherent
(lost) patients. Data collection was done through interviews based
on pre-tested structured schedules, soon after diagnosis and at
the end of treatment. Of the 224 available patients in the cohort,
120 (53.6%) completed treatment, 68 (30.4%) were lost, 29 (12.9%)
died and 7 (3.1%) migrated outside the district.
Persistence of cough at the end of treatment was
significantly more among lost patients. The general profile of the
patients, relating to socio-economic, demographic, literacy and
employment details did not differ significantly between the 2 subgroups.
However, the treatment related factors like distance from health
centre, knowledge of treatment duration, advice on treatment given
after diagnosis, payments made to staff and for tonics were significantly
more among patients lost to treatment. Raising of money to meet
the expenditure, particularly through selling of valuables too was
proportionately more among lost patients. Defaulter retrieval action
was not taken for more than 85% of all eligibles, both among completed
and lost groups. The reasons for non-adherence to treatment as emerged
from the study are mainly related to the treatment organization.
The study results emphasize the need to strengthen
the treatment organization to achieve the desired treatment outcome.
This would also be essential for a successful implementation of
|KEY WORDS: COMPLIANCE; COHORT STUDY; CASE HOLDING;
||Chee CBE, Boudville IC, Chan SP, Zee YK & Wang
||Patient and disease characteristics, and outcome of
treatment defaulters from the Singapore TB control unit a one-year
|| INT J TB & LUNG DIS 2000, 4, 496-503
The annual incidence of TB cases among Singapore
residents fell steadily from 306 per 100,000 population in 1960
to 56/100,000 in 1987 but has since remained at between 50 and 55/100,000.
One of the possible reasons for this non-decline may be persistence
of transmission of TB in the community due to delayed diagnosis,
treatment and ineffective case holding.
Compared to non-defaulting patients as controls,
defaulters were mostly non-Chinese, and those live on their own
or with friends. There was no significant association of defaulting
with age, sex, marital or employment status, disease characteristics,
or treatment-related factors. Seventy per cent defaulted during
the continuation phase of treatment.
The study was a retrospective patient record based
case control study conducted in the TB Control Unit (TBCU), Singapore.
This being the main treatment centre, which treats about 50% of
the cases was the venue of the study. The objectives were to: (i)
identify any demographic, social, disease or treatment-related characteristics
which may be predictive of patients defaulting from treatment; (ii)
assess the effectiveness of home visits as a means of defaulter
recall; and (iii) ascertain outcome in these patients. TB treatment
defaulters were defined as the patients who missed their scheduled
appointments and required a home visit to recall for treatment.
Equal number of controls were randomly selected from non-defaulting
patients who started treatment on the same dates as the defaulters.
Majority of the patients were supplied drugs for self-administration
at home and there were about 10% of the patients who were on DOTS
during the study period.
Of the 44 treatment defaulters, 6 (13.6%) were
contacted directly, 20 (45.5%) through a person at home during the
visit and for 18 (40.9%) a recall letter was slipped through the
door due to no contact with patient or any other person at home.
Following home visits, 20 (45.5%) returned within 7 days. The treatment
outcome was not very encouraging as only 19 (43.2%) completed treatment,
21 (47.7%) were not traceable, 1 was dead and 3 were hospitalized.
However, of the 21 patients who were lost to follow-up, all except
one had culture negative results. The study identifies the future
prediction of default as those who were non-Chinese, living alone,
male and had a previous history of treatment.
|KEY WORDS: DEFAULT; CASE HOLDING; SOCIAL CHARACTERISTICS;
HOME VISIT; SINGAPORE.