The paper presents a comprehensive analysis of the sociological research on TB conducted in India between 1956-1998. Human suffering; health seeking behaviour, factors affecting and improving treatment compliance are the important sociological aspects of TB that have been investigated. The genesis of DOTS has been traced to the long-standing efforts to try different strategies to overcome the problems associated with treatment completion for e.g., development of supervised, intermittent and SCC regimens. Following are the salient conclusions given in this paper:

In the early 60s, the visionary approach of researchers to focus on the sociological and epidemiological aspects of TB ensured that the NTP, from its inception, was socially relevant and epidemiologically effective.
The level of knowledge of TB does not necessarily lead to patients seeking relief or taking treatment regularly. It is the physical suffering which is found to be associated with the action taking. Cough is found to be one of the most important chest symptoms of TB as it prompts patients to take action for relief.

Organizational and administrative factors such as insufficient facilities for management of TB, inadequate and irregular supply of anti-TB drugs, long distance to travel for seeking relief, drug intake or drug collection act as barriers and prevent patients to be adherent for treatment. Training of health providers is essential so that they give accurate advice to patients concerning treatment and manage the TB activities. Certain other actions to improve treatment adherence include decentralization of TB services while ensuring regular supervision of programme activities.

Increased research efforts in sociological aspects of TB are needed for successful implementation of DOTS programme. There is a need to explore the feasibility of including diverse groups such as private practitioners, social & leprosy workers and dais (birth attendants), as DOTS supervisor. We can also investigate the utilization of other agencies like STD booths and pan shops. The barriers to the expansion of DOTS programme should be removed.

The retrospective study aims at identifying a “risk group” among patients treated at the DTC & six PHIs in Kolar district of Karnataka state in order to focus on them for motivation and defaulter actions to improve case-holding. Since there were differences in the number of defaults made by the First Timers (who defaulted for the first time during the first month of treatment) and Others (who defaulted during the subsequent months), an in-depth analysis was undertaken to understand the behaviour dynamics of these two groups.

There were 231 First Timers and 141 Others. The analysis revealed that the First Timers had inferior results for all the parameters of case-holding. Mean Defaults Rate was 0.9 for First Timers & 0.7 for Others; Patients Lost to Treatment were 83% & 61%; Treatment Completion Rates were 25% & 59% and Bacteriological Conversion was 58.5% & 76.9% respectively. Inconsistencies observed in the rapidity of defaulter actions taken suggested a possible lapse in taking defaulter actions. Thus, First Timers could become predictors of default: They constitute the important target group for focussing intensive efforts to improve case holding, which is expected to improve to the extent of 30%.

The feasibility of involving ‘Dai’s’ in supervised administration of an oral 6-month SCC regimen in DTP was studied in 2 districts. A concurrent comparison was made between the Dai Method and the present DTP procedure, called the PHI Method, in terms of treatment completion and cure rates at the end of treatment period. A total of 617 patients were observed; 332 in Dai method and 285 in PHI method. About 68% of patients in the Dai method and 33% in the PHI method took more than 75% of treatment in both intensive and continuation phases. The outcome in terms of smear negativity at the end of treatment period was 86.9% and 72.2% respectively. There were 17 (5.72%) deaths in the Dai method and 16 (8.5%) in the PHI method. Treatment completion and cure rates were significantly higher in the Dai method. It is concluded that Dais can be used for supervised drug administration in DTP for increasing the cure rates.

The feasibility of improving adherence to and outcome of treatment among smear positive pulmonary tuberculosis patients by involving traditional birth attendants (Dais) in administering anti-tuberculosis drugs was earlier studied and 86.9% were reported to be cured, 5.72% had died and 7.38% had remained sputum positive, at the end of 6 months. The present study reports the status of those patients at the end of 2 years. Of the 288 patients eligible for follow up, 283 could be contacted through home visits and interviewed for the presence of symptoms and further treatment taken; if dead, the cause of death was ascertained from relatives. Two sputum specimens were also collected from the contacted patients for microscopy, culture and drug sensitivity tests. At the end of 2 years, 79.6% had remained relapse free 7.42% had relapsed and 3.53% remained sputum positive (chronic cases) while 8.5% had died. Of the 251 patients interviewed, 131 still had chest symptoms, 2 years after treatment, but only 24 of them had bacteriologically positive disease. The remaining 7 sputum positive cases were either having non suggestive symptoms or no symptoms.

In view of the above findings, it is considered that DOTS delivered through Dais is feasible