The research study was an extension of a prior study (Anderson & Banerji, D., 1963) that undertook a one-year follow-up of 784 patients who were diagnosed at the clinic of the State TB Demonstration and Training Center, Bangalore. The study sought to determine, over a three-year period, how the pattern of drug collection among the above patients related to the findings about their bacteriological and sociological status.

This report contains a summary of the material and methods used in the clinic followed by detailed descriptions of the bacteriological follow-up of the patients, the significance of the radiological findings for the initial diagnosis and follow-up of patients and, the methods of sociological investigation. The results of the data analysis are also described in detail. The conclusion drawn from the research was that when TB patients, who actively sought medical help, were offered facilities for drug collection within a reasonable distance from their place of residence and when a "skeletal" organization was made available to supervise the treatment of these patients, it was very unlikely that the patients would continue to suffer from TB without availing themselves of the treatment facilities.

The study was conducted in 1965-66 to ascertain whether an additional visit by a senior member of the domiciliary service staff at the NDTC, such as a Medical Officer or the Chief Public Health Nurse, could help retrieve defaulting patients, after three visits by the Health Visitor during a period of 2-3 weeks had failed. Of the 786 non-cooperators, 531 were visited by the Chief Public Health Nurse. The results showed that more than half (58%) of the non-cooperators could be retrieved by the senior staff member, while 24% completed the treatment thereafter and, 8% were still continuing. Only partial success was achieved with the remaining 16%. Counting those who did not attend at all (331) and those who did not complete treatment after being called (73), the experiment was successful in nearly half the cases (382 out of 786). Therefore, it is recommended that the health visitors’ attempts to retrieve the defaulters must be supplemented by at least one visit from a senior staff member for maximum effort.

To solve compliance problems, they must first be detected by identifying patients who fail to keep appointments, identifying treatment failures, and identifying less overt forms of non-compliance by interviewing patients and performing pill counts and urine tests. To improve compliance, simple, specific instructions about the behaviour desired, must be given. If problems develop, the patients should be heard and obstacles to the desired compliant behaviour should be identified. The regimens to overcome these obstacles must be restructured and the support of family and friends elicited. Behavioural strategies such as verbal encouragement, tailoring, incentives, awards and contracts must be tried. Supervised therapy must be used whenever non-compliant behaviour persists. Institutionalization should be avoided whenever possible, but used if no other options remain. There are several methods of detecting non-compliant behaviour and a growing list of validated ways of improving compliance. Their judicious use can help prevent the additional cost, morbidity and mortality inevitably associated with poor compliance.

Impact of health education, specially, in regard to domiciliary chemotherapy, by exposing the patients to a tape-recorded message in a rural TB clinic, was evaluated. The measure appeared to have signficantly improved self- administration of the drugs as assessed by tape and post-tape regularity of chemotherapy of the patients. (From 28 pre-tapes in 1965 to 72 post-tapes in 1969). The measure also appeared to have improved knowledge in other aspects of TB as found by a comparative study of answers to questions between a group of tape-exposed tuberculous patients and another group of not exposed non-tuberculous persons on taped and untaped questions (on untaped questions, the difference was only 1.5 to 1, whereas on taped questions, this ratio was 18 to 1). It was therefore concluded, as a staff, time, and cost-saving measure, taped or gramophone recorded messages played at the clinic may prove of great educative value, specially for clinics serving predominantly illiterate patients.

The paper emphasises the necessity for research on motivation, particularly, in the context of the NTP, to achieve the goal of getting TB patients to remain sufficiently long on treatment. For any such study, motivation needs to be viewed as a psychological process wherein various social, cultural and situational factors, either singly or in combination may influence motivation and thus, the patient’s behaviour, leading to regular or irregular patterns of treatment. The definition of a motive and its characteristics are presented in a model. The application of the model, explained in terms of the DTP, provides a broader focus in motivational research than the current, limited scope described in the DTP manuals. Viewing motivation as a psychological process allows for the identification of some of the patient’s intrinsic factors, the external factors in the patient’s environment and the factors pertaining to health institutions that could be manipulated for effective motivation. Therefore, the model can serve to make the NTP’s motivational research efforts, comprehensive.

The effect of initial motivation on pulmonary TB patients in terms of regularity of drug collection and pattern of default for three months was studied at LWTDTC, by adopting three different schedules of motivation: (i) motivation as per routine procedures of DTP, (ii) issue of simple brief instructions only and, (iii) motivation with reduced contents and with change in sequence of points. The patients without history of previous treatment were randomly allocated to these 3 groups. All the three groups were similar in respect of age and sex composition, sputum status, extent of disease, duration of symptoms, education level and the distance that the patient had to travel for collection of drugs. However, there were more housewives in Group II.

The findings of the investigations were: Sixty nine patients (49.6%) of the 139 patients in Group I, 60 of the 126 (47.6%) in Group II and, 67 of the 142 in Group III (47.2%) had made all the three collections. On the whole different schedules of motivation did not significantly affect the behaviour of the patients in making all the three monthly collections. However, patients in Group II with simple instructions were more regular and made less number of defaults. There was also a suggestion that sputum negative patients required more than mere instructions. The best response in such cases was in Group III, wherein motivation was neither very elaborate nor very brief and in which sequence of points was so arranged that stress on important points was laid early enough to remain within the recalling memory of the patients.

A controlled study was conducted at LWTDTC, Bangalore, among 250 randomly selected urban patients of pulmonary TB of whom 155 were in the ‘motivation’ group and 95 were in the ‘control’ group. In the motivation group, patients were interviewed by NTI Health Visitor and motivated by LWC staff; a month of drugs (TH) were given. Within 3 days of initiation of treatment they were motivated along with their household members during home visit by NTI staff every month for a period of three months. Control group patients were motivated at the clinic as per the programme guidelines.

In the motivation group, 59.9% of patients had made all the three collections during the first three months compared to 27.8% in the ‘control’ group. During the remaining months also the drug collection was 47% and 35.6% respectively. The drug collection pattern among the patients in the motivation group was found to be better than among the patients in control group who did not have the benefit of home visiting. Sputum conversion was also found accordingly better among the motivation group as compared to control group.

The paper stresses the need for an interdisciplinary approach to the study of drug default among TB patients and presents several studies to discuss the role of motivation in reducing drug default, underscoring the importance of using an action-oriented definition of default. One study, conducted by the NTI, determined the number of defaults and the collection at which default occurred through a retrospective analysis of treatment cards. Analysis of the data collected from 2,419 patients showed that a large proportion of patients, whether they visited the (DTC - specialised institutions) or the Rural PHIs (GHIs), dropped out immediately after starting the treatment. Another study, on the influence of initial motivation, was conducted among adult patients newly diagnosed at the Bangalore LWTDTC. Three types of motivational contents for verbal communication were developed and a total of 407 patients were randomly distributed into three groups. The third study determined the influence of patient and family motivation on the drug collection of TB patients, using 250 newly diagnosed cases of TB at LWTDTC. It was concluded from the three studies that age, sex, education and occupation of the patients did not influence the drug collection pattern. Different schedules of motivation with variable quality of contents and, changed sequence of points did not appreciably affect the TB patients’ behaviour. Sputum-positive cases needed strong and more effective motivation compared to sputum-negative ones. Family motivation had a positive influence on the patients’ drug collection pattern.

A prospective study was carried out to assess the impact of extra motivational efforts on the duration of unbroken drug-continuity in a cohort of 150 randomly selected TB patients undergoing anti-TB unsupervised domiciliary treatment at S.R.N. Hospital, M.L.N. Medical College, Alahabad. The contribution of extra-motivational efforts along with that of some other socio-economic characteristics of the patients, was obtained by the use of multiple regression analysis. It revealed that if monthly additional efforts of extra-motivation are made, devoting 15-20 minutes only in terms of explaining to the patient about the necessity and importance of regular and complete treatment, the average duration of unbroken treatment of a group of patients can be increased by as much as two months, a substantial gain from both curative as well as preventive aspects of any TB control programme.

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.

The article presents the definition and aim of motivation in the DTP, the types of motivation and the factors in effective motivation. It is concluded that motivation, whether direct or indirect, plays an important role in the TB programme strategy. Prevention of default is easier than retrieval of the defaulter. Motivation provided in a proper manner and with the proper perspective can help to minimise the defaulter problem. Every cured patient is a motivator to the community and has a snowballing effect on the improvement of NTP’s performance.

The findings of the Fifth TB Association of India’s SCC trial for the Jaipur Center were reanalysed. Sixty patients with pulmonary TB, who had not received any chemotherapy in the past, were divided into two groups. All the patients were put on isoniazid, rifampicin and pyrazinamide for 8 weeks followed by isoniazid and rifampicin for another 18 weeks. Group A patients were informed of the likely occurrence of anorexia and /or vomiting but Group B patients were not. Routine and default retrieval home visits were given to ensure maximal drug compliance.

Drug toxicity-related early defaults were significantly less common in Group A patients (1 of 30) as compared to group B (6 of 30).

In the context of domiciliary treatment for TB patients, the process of motivation starts from the time the patient enters a clinic for diagnosis or for drug collection. The doctor, the para-medical staff and significant others in the patient’s environment also indirectly play a role in providing motivation. A number of points to be considered in motivating the TB patients are listed.

A pilot study was initiated in 1990 to investigate the feasibility of patient-to-patient motivation by having a patient who had been regular for treatment to talk to a new patient. A controlled study was begun in 1991. Only those patients who were unsuitable for admission to the ongoing controlled clinical trial were admitted to the investigation. A stratified, random procedure was used to allocate patients to either routine motivation (motivation done by clinic staff only) and patient-to-patient motivation (motivation done by treated patients in addition to clinic staff, on admission and, at 1 and 4 months). Defaulter retrieval action was taken for both groups in accordance with the DTP manual. No home visits were made. Patients defaulting after retrieval actions for a month, were considered “lost.” All 297 admitted patients completed six months of treatment. 281 patients remained for analysis (4 died and 16 had change of treatment). Forty percent (143) of 281 patients had more than 90% of treatment in both groups and nearly 60% of lost patients were in the first phase of treatment in both groups. The study revealed that patient-to-patient motivation did not result in any greater improvement in patient compliance.

Four hundred and sixty eight newly diagnosed smear-positive pulmonary TB patients at the DTC, Goa Medical College, Goa, were studied on standard domiciliary therapy. 240 were suffering from alcoholism; 86.8 of non-alcoholics and 71.7 of alcoholic patients received full drug therapy. 9.7 of the controls and 25 of the alcoholic group defaulted. Overall default rate was 20.1 in this study. Alcoholic patients do respond to intensive and repeated motivation and become more compliant.