The inadequate collaboration and co-ordination between the voluntary and governmental institutions should be highly detrimental to patients who after receiving some treatment soon get lost to further treatment because they are not properly referred to health centres near their homes and cannot continue their treatment at voluntary institutions, either, for obvious reasons. The apparent inability of a few voluntary organisations to adapt their activities in line with the modern concepts of TB control may work to the disadvantage of the TB programme of Gujarat state.

The Aga Khan University Hospital, in Karachi, Pakistan, is a 650-bed university teaching hospital. There is little data from Pakistan on the awareness and application of the WHO’s TB treatment guidelines among physicians. This study evaluates physician compliance with these guidelines. A questionnaire to measure physician compliance was developed, pilot tested and standardised. Case records of all patients hospitalized with TB were reviewed (January-December 1995, n = 229), and were classified into WHO Category 1(n = 191), Category 2 (n = 9) and Category 3 (n = 29).

A total of 53 (23%) patients had a diagnostic bacteriological sputum smear examination, of which 38% were smear positive and 47% culture positive. Of 25 cerebrospinal fluid cultures 12% were positive. No sputum smear tests were conducted during treatment. Of 58 patients in Category 1 who completed therapy 74% received a 2-month intensive phase consisting of HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol) (n = 43), while 41% received a 6 month continuation phase with HE (n = 24). Over 70% patients were lost to follow up, more than half of these during the intensive phase.

The study reflects poor awareness of the WHO guidelines and low compliance among physicians, and a high loss to follow-up. Efforts are needed to create physician awareness about the WHO guidelines and their use. This study can be used to assess the effectiveness of any future physician education and to identify areas of weakness in health care.

Case finding under the NTP in India is a passive process limited to chest symptomatics in the community who attend government health institutions on their own for relief of symptoms. It is, therefore, essential that the community is aware of the basic facts about TB. This study was undertaken in 24 randomly selected villages of Sri Perumbudur (Tq), Chengai Anna (Dist) Tamil Nadu to assess the initial level of knowledge about TB and again after providing health education on TB to evaluate its effectiveness after 2 years. Every fifth household starting from randomly chosen location was visited by Medical Social Worker (MSW) and a total of 466 respondents were interviewed. The head of the household or in his or her absence any other responsible family member was interviewed to find out the initial level of knowledge of TB using a pre-tested semi-structured interview schedule. The community was then educated about the important aspects of TB by means of pamphlets, film shows, exhibitions, role plays and group discussions. After two years, in the same households, 433 (93%) respondents were interviewed using the same interview schedule.

Two-thirds of the respondents were females and half of them were in the age group of 25-45 years. As regards literacy status, 53% were illiterates. There was an overall increase of knowledge on various aspects of TB, ranging from 18-58%. In all, 45% respondents initially and 91% after health education answered correctly that both rich and poor are affected by TB, 38% initially were aware that both adults and children are affected by TB and afterwards 93% were aware of these facts. Prior to health education, 37% knew prevalence of TB is similar in urban and rural areas, this increased to 95% after health education. Regarding knowledge that investigation and treatment facilities are available free of cost at Govt. Health Institutions 67% to begin with and almost all 98% afterwards responded correctly. About the need of examining the close family members of TB patients, 67% were initially aware and after health education, it increased to 98%. Further 15% were aware of cough hygiene prior to health education, which increased to 48% subsequently.

As regards the source of information on TB, 70% mentioned verbal communication, i.e., through TB patients and others, as the major source followed by pamphlets (21%), mass media (14%) and others (15%).

It is necessary to consider the type of community and the available resources while planning health education strategies. For health education to be effective, and sustained, it should be a continuous process.

Patients hospitalized in Kentucky (USA) TB sanatoriums were interviewed to determine the degree of understanding of their disease and its implications in preparation for ambulant care. Eighty percent knew their diagnosis and 56 percent recognized TB as contagious. Although two-thirds could give at least a visual description of their medication, at least 50 percent demonstrated a deficiency in knowledge that was needed to be corrected before adequate compliance away from the hospital environment could be expected. Further, only 25% knew the criteria for discharge. Among the several patient factors analyzed to explain the difference in knowledge levels, only age was consistently significant. Positive effort was recommended to educate the patient for adequate ambulant or home treatment.

The necessity for this study arose due to our desire to learn first hand the reactions and reasons for irregularity and non-cooperation of the party i.e the patients. No doubt health visitors on repeated visits try to find out the main cause of irregularity; yet we felt that since health visitors are known to be a part of this institution, the patients may not tell them the real behind their non-cooperation. We felt that the students of the Delhi school of social work being unconnected with the centre and also by possessing proper attitude for this work would be able to bring out the real reasons.

The study, a collaboration between the National Tuberculosis Institute, Hanoi, Vietnam and the Karolinska Institutet, Stockholm, Sweden, was carried out in a district of Quang Ninh Province in North Vietnam.

To describe TB services, attitudes of staff and attitudes of patients considered as defaulters to TB treatment.

Two focus group discussions were carried out with staff at the district hospital. Ten defaulter patients were interviewed in their homes.

This exploratory study has revealed some important aspects of staff and patients’ attitudes to TB and its treatment. TB is considered a ‘dirty’ disease, which mainly affects poor people. There is a tendency to avoid telling others about it. Obvious symptoms are explained as ‘being over-worked’. A patient with TB feels ‘less respected’ by others. The social stigmatization leads to delays in seeking medical care, often only after self-medication: anti-TB drugs can be brought without prescription in various pharmacies. The patient’s economic situation is also an important determinant of compliance and non-compliance. These factors need to be taken into consideration in TB control in Vietnam.

The control of TB and its eventual eradication throughout the world will be slow if clinical and epidemiological procedures alone are used. However, if the health education process is added at the administrative level, and sufficient qualified health education specialists engaged, the eradication may proceed more rapidly. More people will assume greater responsibility for their own health protection, local communities will show stronger leadership for their own health programs and, public health and TB services will be strengthened. Health education practice has met the demands of the period since the major change in TB therapy was instituted in 1944.

All public health programmes are for the benefit of the public and their success depends on public co-operation and, voluntary participation is hard to obtain even in programmes for its good. The purpose of health education is to resolve this paradox by concerning itself with the task of bringing about a change in knowledge, feelings and behaviour of the people so that practice of healthy living and participation in health programme can be ensured. Twelve basic principles of health education in TB, to achieve this purpose, are listed.

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.

This paper describes the need for a Health Education Component in the NTP. The potential achievement of the programme activities viz., prevention, case finding and treatment has been established by studies conducted by the NTI. Corrective measures to achieve the potential would no doubt have to tackle all the three constituents of the programme viz., objectives, activities and resources. However, incorporation of a health education component in the crucial activities of the programme would help, where, under-achievement is due to the lack of knowledge and proper attitude both on the part of the patient and the health worker. In order to evolve an effective methodology, the goals of the health education component should be synchronised with those of the programme. While the health education aspects in the case-finding and treatment activities can be incorporated at health institutions and on an individual or group basis, education for the preventive activities has to be on a mass or community basis. While the nucleus of the community education should be on BCG vaccination, the mass media could be utilised for the overall TB education in the general population. Thus, there is scope for employing a variety of material, methods and media of health education in the NTP.

The author emphasises the need to take a holistic approach to health education. In India, changes in the curricula of medical colleges have not gone far enough to change the prevalent focus on disease and the attitudes and practices that go with it. Some pragmatic social scientists have recognized that health education is needed, not only for the general public, but for health administrators and teachers of TB and chest diseases too, in order to change their behaviour. Therefore, they suggest that to generate additional felt need among the people, health education is needed only when the existing felt needs of the people have been met and there is surplus capacity left to meet the extra needs. This, then, is the need-based cutting edge of health education.

Two adjacent Cape Town Local Authority health clinics in Cape Town, South Africa, were selected. Clinic A was designated the "intervention clinic" and Clinic B the ‘control clinic’. To asses whether the combined strategy of a patient-centred interview plus the issuing of a patient education booklet would have the effect of increasing the adherence of notified pulmonary TB patients to prescribed treatment.

A controlled intervention study was implemented using a cohort of the first 60 consecutive patients notified with pulmonary TB at both Clinic A and Clinic B; the patient cohort thus consisted of 120 patients. The risk of patient non-adherence to anti-TB treatment was significantly reduced at the intervention clinic compared to the control clinic.

The results of this study indicate the need for further operational research to assist health providers in developing standardised protocols of health education to enhance adherence to treatment in patients who require protracted treatment regimens.