In Pakistan, TB is a major health problem and is perceived as a stigmatised disease. Implementation of DOTS is limited to only few districts due to poor functioning of primary health care and inability to strengthen them before DOTS implementation. Bethania Hospital (BH) in Sialkot town of Punjab province in Pakistan is the acknowledged centre for treatment of TB patients since 1970. Still the major problem faced by BH has been poor compliance. Various alternatives to improve compliance were tried e.g., hospitalization for initial 6 weeks, introduction of SCC of 8 months, which had some improvement, but was not appreciable as SCC regimen had 12% initial defaulter and 34% of these put on treatment did not complete the treatment.

Keeping in view the social attitude and the health beliefs of the local people, it was decided to offer intensive counselling to improve treatment adherence. The objective of the study was to assess the overall impact of counselling on treatment defaulting and to identify sub-groups in which counselling was the most effective. The statistical design was a randomised controlled intervention trial. A total of 1019 adult TB patients were interviewed and taken into the study and the control group during full one year of 1995. Baseline data were obtained through semi-structured interviews by trained para-medicals of both genders and belonging to the same socio-economic background. Patients were followed until the end of treatment. The counselling was given at the start of treatment and at each subsequent visit for ambulatory patients, or weekly for hospitalized patients in the study group. The counselling, combined health education with strategies was aimed to strengthen the self-efficacy. Control group patients received the usual care. According to treatment policy, patients scheduled for SCC were advised to accept hospitalisation for the 2 months of intensive phase of treatment. Ambulatory patients mainly received a 12-month regimen. Of the 63% of patients who accepted hospitalisation, only 40% remained hospitalised for the full 2 months. The outcome measure was treatment default, cure, referral or death. Results showed that the default rate was 54% in the control and 47% in the intervention group; the default risk ratio was 8.7, implying a reduction in defaulting of 13%. Intensive counselling has a significant, although limited, impact on treatment adherence. The impact was stronger in women, ambulatory patients, re-treatment patients, women who worked at home, and patients who were not the main providers, those with poor knowledge of the disease or those with a short treatment delay. Counselling does not eliminate the need for closely supervised treatment but it is a useful additional strategy for improving treatment adherence. In the long run counselling has the potential to reduce the stigmatisation of TB patients. In countries like Pakistan, where the implementation of DOT is currently hampered by the absence of functional health infrastructure at the peripheral level, the combined strategy of counselling and family based DOT could offer a valid alternative to the immense and urgent problem of TB control.