Community involvement in the TB control programme has always been considered to be a very important factor. The Rotary Club of Surendranagar District, Gujarat, was entrusted with the work of organising active case detection camps in the district. The case detection work was done by a mobile odelca unit and the laboratory team. The results were handed over to the Rotary Club. The Rotarian volunteers, with the help of the DTC, supervised the regularity of collection and consumption of treatment drugs. Fifteen(15) such camps were held for the chest symptomatics. A total of 5,648 mini X-rays were done and 5077 sputa were examined. A total of 1,395 radiologically active cases were detected. The involvement of volunteers significantly helped in: 1) Early and increased detection of cases, 2) Reducing the financial burden of the treatment by providing the needed drugs to all detected cases, 3) Increasing case holding by voluntarily contacting all the patients in the area, 4) Increasing the public’s awareness about the TB problem and helping in providing the necessary health education. This collaborative effort resulted in 78.3% of the cases completing the treatment. It was concluded that community involvement, as in this study, improved the performance of the TB control programme.

Enlisting co-operation of TB patients in adhering to the prescribed drug regimen, dosages, regularity of drug intake and completion of treatment, under the condition of a private medical practice in India is of topical interest.

It is a common belief that private medical practitioners do not take adequate efforts to offer organized medical care to TB cases due to various reasons. The study was undertaken by a private medical practitioner himself to highlight the TB treatment management under a private medical practitioner. Of the study cohort of 307, 20-25% were from Bikaner city, another 25-30% from Bikaner district, rest were from neighboring districts. Of the total patients, 211 comprised of newly diagnosed and 96 of previously treated patients. They were all registered at the author’s private clinic from 1st Oct 1991 to 31st Dec 1995.

The SCC regimen chosen was 2EHRZ/4HER/3HR and self-administered at home. The regimen and the frequency of monitoring check up in the present study are somewhat different from those recommended under the NTCP. Around 20% of the expected irregularity in drug intake was sought to be covered by prolonging the treatment period from 6 months to 9 months so that each case has the best chance of completing at least 7 months treatment in 9 months. Great care was taken that patients take at least 3 drugs in the initial phase of 2 months.

Personal motivation was given by the private practitioner to the patient and/or family members at each visit and monthly visits which helped the practitioner to maintain a good level of health education and establishing motivational support with patients.

Patient co-operation during the study was quite satisfactory. More than 2/3 of the patients were regular in coming to the clinic. As told by the patients at the time of follow up visits, upto 80% had taken their treatment regularly for 7 months or more in 9 months. There was hardly any difference between the newly diagnosed and previously treated patients in this regard. Of the 307 patients in the cohort 244 (80%) were available for assessing the efficacy of treatment at the end of 9 months. The bacteriological conversion among those previously treated and newly diagnosed was 85% and 90% respectively.

This study demonstrates that a Private Medical Practitioner with minimum infrastructure too can provide anti-TB drug delivery and regular motivation at clinic without difficulty. Therefore, satisfactory results obtained comparable to any good public sector control programme are due to good services provided by the practitioner. Adherence to treatment was the same in both previously treated and untreated cases which suggests that if a reasonable care is provided, the previous poor experience is no bar to enlist co-operation to get good results.

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.

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.

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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s community can prove invaluable. Ideally, this would be an individual who knows the patient and the patient’s 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.

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 DOTS strategy.

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.

Sixty freshly diagnosed bacteriologically confirmed cases of pulmonary TB were thoroughly motivated and success of motivation was assessed using a 10-point “Motivation Assessment Scoring Scale”. The results of regularity of treatment in this group (group `A`) were compared with a comparable group of 60 patients (group `B`) motivated routinely at DTC, Shimla. Seventy percent of group A cases received at least 12 monthly collections regularly as compared to 40 percent in group B (P< 0.05). The need for using the Scoring Scale for assessing success of motivation, in order to achieve better case holding results, is discussed.

Treatment default and premature discontinuation of treatment continue to be major constraints for the successful implementation of the NTP. In order to assess the influence of motivation in overcoming this problem and improving patient compliance, a study was conducted at three of the major centres, namely, DTC, Vellore, and general hospitals at Gudiattam and Vaniyambadi in Tamil Nadu. All new smear-positive patients initiated to treatment between October, 1987 and April, 1989 were admitted to the study. In all, 278 patients were motivated. There was an increase in treatment completion rate among patients who had motivation initially. This was more evident in patients who had repeated motivation.

Non-adherence to treatment by patients is a major impediment, worldwide, in controlling TB. Failure of approaches attempted so far, in effectively tackling the problem of non-adherence, has led to the inclusion of directly observed or supervised chemotherapy as an essential element of the WHO's revised strategy for global TB control. Supervise chemotherapy has also been made the most important component of India's NTP being revitalized with the help of a loan from the World Bank and technical assistance from WHO. The reason for advocating supervised chemotherapy in India is the failure to ever achieve desirable cure rates, under a well designed NTP in operation for ever 3 decades. The demonstration projects of several NGO's, claiming success in achieving high cure rates, rarely provide hard data as evidence and their results are often considered anecdotal and unsuitable for wider application. This paper presents alternative approaches adopted by two NGO‘s providing services to large populations in different settings, one a most backward area of rural Gujarat and the other in the slums of Bombay. Both organizations could ensure reasonably high levels of treatment completion and cure rates under field conditions. While the urban NGO used pre-registration screening and motivation as tools to ensure treatment completion and cure, the rural NGO successfully employed the services of the female anganwadi workers of the Integrated Child Development Services(ICDS) scheme. The reproducibility and wider applicability of some important elements of these approaches are discussed.