This study based on an individualistic model examines the significance of factors such as symptom awareness, knowledge about the disease, recall of clinic instructions, economic problems and social interaction in the treatment regularity of patients with pulmonary tuberculosis through a multi dimensional comparison of regular patients, irregular patients and their households. There was no difference in the symptom awareness of the two groups of patients. Thus frequency of medical visits is to adopt the sick role than of stress. In NTP patients are denied the sick role has “rest” and “special diet” the vital elements of traditional treatment are not recommended as part of treatment. Yet, three of the four cardinal symptoms of pulmonary tuberculosis, cough fever and haemoptysis being of a nature observable by others, have been observed by the households to the extent similar to patients awareness. Most of the patients who take treatment from non- paying centres such as the LWTDTC live in overcrowded areas where there is generally a high degree of neighbourhood interaction not only social but in sharing common utilities such as courtyard, water tap, bath room, toilet etc. It is therefore not surprising that nearly half of the patients and households said that the neighbours knew about the patient's illness.

Seeking multiple sources of treatment is a common behaviour pattern of patients. Yet, it is disconcerting to find that tuberculosis patients who can ill afford to pay and who need to be under treatment for a long period should 'shop around' for treatment. It is the irregular patients who have sought treatment at other agencies more often. The study shows that patients showing regular drug collection have had help from household members in collecting the drugs. They have also had help from household members in remembering to consume the drugs. More of the households of the regulars mentioned LWTDTC as the place of treatment while in the in case of the households of the irregulars mentioned several places of treatment.

No significant differences were seen between the regular and irregular patients in their social interactions within the households or in the behaviour of households towards the patients. To the household, economic difficulties were the most important, perhaps for the reason that the patients were men in the working age group. Though economic difficulties were important to patients also the predominant aspect was pain and discomfort the physical dimensions of suffering. A treatment agency that can pay adequate attention to the relief of physical suffering and non- relapse of symptoms can perhaps help to improve treatment regularity of tuberculosis patients appreciably.

Tuberculosis control by mass domiciliary chemotherapy is now being attempted on an increasingly large scale in the technically underdeveloped countries. The National TB Institute (NTI), Bangalore is an important centre for the development of such programmes and a study reported in this paper is an enquiry into the working of an urban tuberculosis programme which is operated under the auspices of the Institute. The excellent results of controlled clinical trials have lead to widespread belief that tuberculosis problem can be reduced significantly and rapidly by use of mass chemotherapy. However, the findings of such programmes elsewhere showed that by a long term continuous effort year after year, the removal of infectious cases can bring about a gradual reduction of the problem. Hence, it was necessary to study the treatment organisation of domiciliary chemotherapy on a large scale in respect of patients’ behaviour towards the programme during the treatment period. Three types of problems encountered in an urban tuberculosis programme are dealt in this paper: (1) problems related to the patients who are under treatment at the Lady Willingdon TB Demonstration & Training Centre (LWTDTC); (2) patients who prefer to take treatment from other institutions and (3) patients who come from outside the city. Study population consisted of 784 radiologically positive patients diagnosed at the LWTDTC from March 61 to May 61. All the outpatients were submitted to a tuberculin test and examination by a 70 mm photofluorogram. Those who were X-ray positive were given bacteriological examination of a spot sample of sputum by both smear and culture on their second visit scheduled on the third day. Of the 784 persons 318 (54%) were found to excrete tubercle bacilli. All patients suffering from active tuberculosis and sputum positive disease were put on a treatment regimen of 300 mg of isoniazid per day for a period of one year. During the course of the study a few of the sputum positive cases were given 10 gms of PAS in addition. The study population was interviewed by the Social Investigators of NTI: initially at the clinic immediately after their diagnosis, defaulters at their homes within four weeks of their defaulting and all patients after twelve months of treatment period. The coverage was 100%, 65% and 76% respectively.

The major problems identified and quantified were: Of the 784 patients under study, 84 (11%) did not even return to learn the results, 46 (6%) patients houses could not be traced, 138 (17%) resided outside the city, 48 (6%) emigrated during the treatment, 173 (22%) took treatment from outside sources, 156 (20%) took treatment regularly from the clinic and 139 (18%) also took treatment in the clinic but irregularly. Various reasons were given for defaults in drug collection, a sizable proportion of which could have been avoided through better organisation and administrative procedures and good initial motivation at the clinic. Default is a complex behaviour pattern and this study did not bring out any correlation between default and the economic, social, educational or other status of the patient. With changes in the system leading to a good treatment organization, it should be possible to have a higher percentage of regular patients than 20% as at present. About 64% sputum conversion among regular patients and estimated 25% among defaulters was observed.

This investigation was to find out the drug consumption among tuberculosis patients put on domiciliary self administered chemotherapy, in terms of proportion of patients that make various levels of drug collections and proportion among them that consume drugs at different points of time during the course of treatment. In all, 816 tuberculosis patients aged 5 years and above residing in Bangalore city were admitted to the study. They were randomly divided into 6 groups at the time of inclusion into the study, for examination of urine samples for the presence of INH and PAS. One surprise urine sample was collected from each patient at the pre determined time after the drug collection. The samples of urine were collected from one group at first month, another at second month, third at fourth month, fourth at sixth month, fifth at ninth month and sixth at twelfth month of treatment. Urine samples were collected within 33 days of drug collection for the month because the drugs were supplied at a time for the said period. Urine specimens were examined for the presence of drugs or their metabolites. For INH, NM test & acetyl INH test and for PAS, ferriechloride and case test were performed. The drug collection was judged on the basis of treatment record and its consumption on the basis of results of urine examination.

Of the total patients included in the study, 54% made 10 or more drug collections over a period of 15 months. The initial radiological or bacteriological status or severity of disease did not influence the drug collection; however smaller proportion of old persons in both sexes collected the drugs for 10 months or more. Urine specimens of 71% of patients who had collected drugs were positive for INH on any one day. Bacteriological quiescence was obtained among the 82% INH sensitive patients who had made 10 or more collections. The above findings suggest that the patients who collect drugs also consume with fair amount of regularity and achieve a high degree of bacteriological quiescence.

The paper presents some aspects of domiciliary management of tuberculosis patients in a District Tuberculosis Programme (DTP) viz., the interval between diagnosis and initiation of treatment, regularity in collection of drugs, role of motivation of patients for collection of drugs and pattern of defaulter retrieval actions by health institutions. The treatment cards of 3089 patients of pulmonary tuberculosis belonging to Bangalore DTP diagnosed during 1964 were analysed. The cohort of 2479 patients was divided into 3 groups according to the place of treatment, viz., (i) those treated at District Tuberculosis Centre (DTC) where better trained staff motivated tuberculosis patients & took defaulter actions (ii) the Urban Peripheral Health Institutions (UPHIs) where motivation and defaulter actions were taken by specialised staff and (iii) rural PHIs where non- specialised general health workers along with general duties did motivation and took defaulter actions.

The study has shown that in the entire district about 94% of patients were put on treatment within 10 days of diagnosis. In rural PHIs, among 14.5% of patients the treatment was started after 10 days of diagnosis. For the 149 initial defaulter patients, actions were taken only for 39% of the patients, lowest being in rural PHIs (10.8%). The defaulter actions for 69% were taken in time, more promptly by DTC staff for DTC & UPHI i.e. 71.5%, whereas rural PHIs were poor in this respect and only 37.5% of the actions were taken on time. Sputum positive cases collected drugs more often than sputum negative and also more patients collected drugs on due dates at DTC in comparison with PHIs. Both the differences were statistically significant.

About one third of the lost patients came from those who made the first default. About 55-63% and 75-82% of this group defaulted by the second and third collections respectively. Defaulter actions were not taken by rural PHIs for 66.7 to 72.5% defaults, while DTC staff had not taken defaulter action for about 20% of defaulters and 67.8% of such actions were prompt in DTC, whereas it was only 19.3% in rural PHIs.

A controlled study was conducted at Lady Willingdon Tuberculosis Demonstration and Training Centre (LWTDTC), Bangalore among 250 patients randomly selected urban patients of pulmonary tuberculosis of whom 155 were in the 'motivation' group and 95 were in the 'control' group. In the motivation group, patients were interviewed by National Tuberculosis Institute 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 high rate of treatment completion and the regularity of drug intake achieved in clinical trials of Short Course Chemotherapy (SCC), could possibly be attributed to efficient organizational set-up, careful selection of cases and all-out effort to control defaulters. The organizational effort put forth to achieve the regularity is relevant to the applicability of SCC in the existing set-up of District Tuberculosis Centres (DTCs) under National Tuberculosis Programme (NTP). First 300 patients admitted to SCC trial to assess the efficacy of three drug regimens of 3/5 months duration under fully supervised conditions, carried out jointly by National Tuberculosis Research Centre, Madras and National Tuberculosis Institute (NTI), Bangalore, have been analysed for the purpose.

To keep up the regularity, 1/3rd of the patients required home visits-some of them repeatedly. If the actions of the same intensity of defaulter retrieval in the form of home visiting are envisaged to be taken in a DTC with the normal working pattern catering to 500 patients, 250 to 300 home visits will have to be made in a month. This may not be feasible in the existing set-up of NTP. A new strategy of defaulter retrieval actions for programme conditions may have to be devised. Further, selection of drug regimen which has the maximum potential of being given on self-administered basis may reduce the work-load to a considerable extent. Drug toxicity, side effects and the cost of drugs may not be major handicaps. However, the only way to understand various operational problems is to undertake scientific operational studies in actual working conditions of NTP.