Today, treatment of TB has developed into the concept of “case-holding” which involves the health agency, the patient, his/ her family and the community for the completion of treatment by the patient. The drug regimen plays a relatively minor role in case-holding when compared with other factors such as the active participation of the patient, family and close friends, the attitude and behaviour of the health staff who offer the treatment and, a constant supply of drugs and their availability to the patient. The services offering the treatment play a major role in reducing drug-default which is a primary problem in case-holding. The drug-default pattern in different situations is listed and the reasons for drug-default are discussed under three categories, technical, organizational and, administrative and socio-psychological.

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.