What are the reasons for patients not adhering to their anti-TB treatment in a South African district hospital?

A comparative analysis of the profile and treatment outcomes of tuberculosis patients managed at the community and primary health care facilities in Botswana

Background

Successful treatment of Tuberculosis (TB) is necessary for mitigating and averting millions of deaths annually. This study compared the profiles and measured the association between patients, health system-related factors, and TB treatment outcomes of patients managed through the community tuberculosis care model with those managed in primary health care settings.

Methods

A retrospective multicenter cross-sectional study was conducted in six districts in Botswana. Patient's records were reviewed using a data extraction sheet, and data not captured on registers were obtained using a structured questionnaire.

Results

Three hundred and twenty-four TB patients were sampled. Most participants (84 %; n = 273) were receiving community-based DOT. Patients with moderate TB knowledge (OR 5.3,955 CI 1.01-27.7), good perception of TB care (OR 11, 95 % CI 1.29-94.0), were more likely to enroll for community DOT and achieve treatment cure. Those in businesses (OR 3.85 95 %CI 1.10-22.6), always had treatment available (OR 3.66, 95 % CI 1.12-11.4), never drank alcohol (OR 2.11, 95 %CI 1.06-4.19), used their vehicle (OR 2.11.95 %CI 0.99-4.48) were likely to enroll for community DOT.

Conclusion

A patient-specific education program and continuous improvement practices to increase patient TB knowledge and satisfaction should be implemented at all levels to improve treatment outcomes.

Risk factors for poor engagement with a smart pillbox adherence intervention among persons on tuberculosis treatment in Ethiopia

BACKGROUND

Non-adherence to tuberculosis treatment increases the risk of poor treatment outcomes. Digital adherence technologies (DATs), including the smart pillbox (EvriMED), aim to improve treatment adherence and are being widely evaluated. As part of the Adherence Support Coalition to End TB (ASCENT) project we analysed data from a cluster-randomised trial of DATs and differentiated care in Ethiopia to examine individual-factors for poor engagement with the smart pillbox.

METHODS

Data were obtained from a cohort of trial participants with drug-sensitive tuberculosis (DS-TB) whose treatment started between 1 December 2020 and 1 May 2022, and who were using the smart pillbox. Poor engagement with the pillbox was defined as (i) > 20% days with no digital confirmation and (ii) the count of days with no digital confirmation, and calculated over a two evaluation periods (56-days and 168-days). Logistic random effects regression was used to model > 20% days with no digital confirmation and negative binomial random effects regression to model counts of days with no digital confirmation, both accounting for clustering of individuals at the facility-level.

RESULTS

Among 1262 participants, 10.8% (133/1262) over 56-days and 15.8% (200/1262) over 168-days had > 20% days with no digital confirmation. The odds of poor engagement was less among participants in the higher stratum of socio-economic position (SEP) over 56-days. Overall, 4,689/67,315 expected doses over 56-days and 18,042/199,133 expected doses over 168-days were not digitally confirmed. Compared to participants in the poorest SEP stratum, participants in the wealthiest stratum had lower rates of days not digitally confirmed over 168-days (adjusted rate ratio [RRa]:0.79; 95% confidence interval [CI]: 0.65, 0.96). In both evaluation periods (56-days and 168-days), HIV-positive status (RRa:1.29; 95%CI: 1.02, 1.63 and RRa:1.28; 95%CI: 1.07, 1.53), single/living independent (RRa:1.31; 95%CI: 1.03, 1.67 and RRa:1.38; 95%CI: 1.16, 1.64) and separated/widowed (RRa:1.40; 95%CI: 1.04, 1.90 and RRa:1.26; 95%CI: 1.00, 1.58) had higher rates of counts of days with no digital confirmation.

CONCLUSION

Poorest SEP stratum, HIV-positive status, single/living independent and separated/ widowed were associated with poor engagement with smart pillbox among people with DS-TB in Ethiopia. Differentiated care for these sub-groups may reduce risk of non-adherence to TB treatment.

Impact of mental disorders on active tuberculosis treatment outcomes: a systematic review and meta-analysis

BACKGROUND

Comorbid mental disorders in patients with tuberculosis (TB) may exacerbate TB treatment outcomes. We systematically reviewed current evidence on the association between mental disorders and TB outcomes.

METHODS

We searched eight databases for studies published from 1990-2018 that compared TB treatment outcomes among patients with and without mental disorders. We excluded studies that did not systematically assess mental disorders and studies limited to substance use. We extracted study and patient characteristics and effect measures and performed a meta-analysis using random-effects models to calculate summary odds ratios (OR) with 95% confidence intervals (CI).

FINDINGS

Of 7,687 studies identified, ten were included in the systematic review and nine in the meta-analysis. Measurement of mental disorders and TB outcomes were heterogeneous across studies. The pooled association between mental disorders and any poor outcome, loss to follow-up, and non-adherence were OR 2.13 (95% CI: 0.85-5.37), 1.90 (0.33-10.91), and 1.60 (0.81-3.02), respectively. High statistical heterogeneity was present.

INTERPRETATION

Our review suggests that mental disorders in TB patients increase the risk of poor TB outcomes, but pooled estimates were imprecise due to small number of eligible studies. Integration of psychological and TB services might improve TB outcomes and progress towards TB elimination.

Factors associated with stroke survivors' inconsistent uptake of physiotherapy interventions at Turton Community Health Centre, KwaZulu-Natal

Background

Stroke is one of the major causes of physical disability worldwide. Whilst physiotherapy interventions are important for the recovery of stroke survivors, the uptake remains inconsistent and factors contributing to these inconsistencies are not well documented, especially in South Africa.

Objectives

The overall objective was to determine the intrinsic and extrinsic factors associated with adult stroke survivors’ inconsistent uptake of physiotherapy interventions at Turton Community Health Centre, Ugu District, KwaZulu-Natal, South Africa.

Methods

This was a cross-sectional study involving 50 stroke survivors who missed one or more of their physiotherapy appointments and 25 who attended all their appointments (comparison group) within a 2-year period. A researcher-administered semi-structured questionnaire was used to collect data, which was captured and analysed using SPSS v25. Results were summarised using descriptive statistics. Pearson’s chi-square test was used for bivariate analysis.

Results

Only two intrinsic factors were significantly associated with the outcome variable, namely: believed in exercises recommended by physiotherapists (χ² = 3.86, p = 0.049) and improvements noted from the start of recommended exercises (χ² = 9.439, p = 0.007). Transportation, including hiring of private cars (74%) and being far away from the health facility (48%), were key extrinsic challenges affecting access to health facilities.

Conclusion

Personal reasons and the difficulty in accessing health facilities were main factors affecting stroke survivors’ uptake of physiotherapy interventions.

Clinical implications

Design of patient-tracking and family support systems may potentially improve the stroke survivors’ uptake of physiotherapy interventions.

Association between tuberculosis and depression on negative outcomes of tuberculosis treatment: A systematic review and meta-analysis

Background

Depression is a common comorbidity of tuberculosis (TB) and is associated with poor adherence to treatment of multiple disorders. We conducted a systematic review to synthesize the existing evidence on the relationship between depression and negative outcomes of TB treatment.

Methods

We systematically reviewed studies that evaluated depressive symptoms (DS) directly or indirectly through psychological distress (PD) and measured negative treatment outcomes of drug-sensitive pulmonary TB, defined as death, loss to follow-up, or non-adherence. Sources included PubMed, Global Health Library, Embase, Scopus and Web of Science from inception to August 2019.

Results

Of the 2,970 studies initially identified, eight articles were eligible for inclusion and two were used for the primary outcome meta-analysis. We found a strong association between DS and negative TB treatment outcomes (OR = 4.26; CI95%:2.33–7.79; I² = 0%). DS were also associated with loss to follow-up (OR = 8.70; CI95%:6.50–11.64; I² = 0%) and death (OR = 2.85; CI95%:1.52–5.36; I² = 0%). Non-adherence was not associated with DS and PD (OR = 1.34; CI95%:0.70–2.72; I² = 94.36) or PD alone (OR = 0.92; CI95%:0.81–1.05; I² = 0%).

Conclusions

DS are associated with the negative TB treatment outcomes of death and loss to follow-up. Considerable heterogeneity exists in the definition of depression and outcomes such as non-adherence across the limited number of studies on this topic.

Community perspectives on tuberculosis care in rural South Africa

Patient nonadherence to tuberculosis (TB) treatment is an ongoing challenge, particularly since the advent of drug-resistant TB and complications posed by HIV/AIDS. Some solutions may lie in understanding patient and community perspectives about barriers to TB care and treatment adherence. Using a qualitative framework, we explored community perceptions and beliefs about TB and perceived facilitators and barriers to care in a rural South African community affected by TB. We were particularly interested in capturing cross-cutting themes and the "merged voices" of participants. Interviews were conducted in 2013 and 2014 with 43 participants, including home-based care workers, clinic staff, patients living with TB and community members in and around a primary healthcare clinic. The data were analysed using principles of thematic analysis. The study reveals the complex interplay between contextual factors and community understandings of the disease. Cultural beliefs about causality and treatment-seeking paths were often mentioned in conjunction with biomedical views. There was a strong interface between TB and HIV in this community, and knowledge of TB was often confused with HIV. HIV-related stigma has been extended to those living with TB. The impact of poverty on treatment adherence was a particularly important theme. Other themes related to the role of the clinic in the community. Our study highlights the socioeconomic vulnerability of this community and the fragility of existing care systems. The findings reinforce the need for a community-centred approach to TB care that takes cognisance of lifeworld issues. We discuss some implications of this study for practice and policy.

Factors Associated with Participation in Pulmonary Tuberculosis Screening Using Chest X-Ray among Diabetes Mellitus Type II Patients in Denpasar, Bali, Indonesia

Diabetes mellitus (DM) increases the risk of developing pulmonary tuberculosis (TB) disease. Therefore, pulmonary TB screening among DM patients is essential. This study aimed to identify factors associated with participation of DM type II patients in pulmonary TB screening using chest X-ray. This was a cross-sectional analytic study and was part of TB-DM screening study in Denpasar, Bali, Indonesia. The sample consisted of 365 DM type II patients selected by quota sampling among DM type II patients joining the screening program from January until March 2016 in 11 public health centres in Denpasar. Data were collected via structured interviews. The contributing factors were determined by modified Poisson regression test for cross-sectional data. From the findings, less than half (45.48%) of DM type II patients participated in chest X-ray examination for TB. Factors associated with participation in pulmonary TB screening were having a higher educational level [APR = 1.34, 95% CI (1.07–1.67)], having family member who developed pulmonary TB disease [APR = 1.47, 95% CI (1.12–1.93)], the travel time to referral hospital for screening being ≤ 15 minutes [APR = 1.6, 95% CI (1.26–2.03)], having health insurance [APR = 2.69, 95% CI (1.10–6.56)], and receiving good support from health provider [APR = 1.35, 95% CI (1.06–1.70)]. Therefore, training for health provider on providing counselling, involvement of family members in screening process, and improving the health insurance coverage and referral system are worth considering.

Relationship Between Proactive Coping and Self-Care Management in Patient with Pulmonary Tuberculosis

Introduction: Patient with pulmonary tuberculosis not only experience physical problems but also face psychosocial problems and it can get worse during the treatment phase that gives impact on patients’ self-care. In order to prevent further impacts on patients, proactive coping is needed.  This study was aimed to identify the relationship between proactive coping and self-care management in pulmonary tuberculosis patients.Methods: This study was a cross-sectional research. As many as 105 respondents taken with consecutive sampling technique. The inclusion criteria of respondent were pulmonary tuberculosis patients both in intensive and continuous phase. This research was conducted in three primary public health care center in Surabaya, East Java, Indonesia. The variables were proactive coping that was measured by Proactive Coping Inventory (PCI) and self-care management that was measured by Self-care Management questionnaire. The data was analyzed using Spearman test.Results: This study showed that proactive coping had a positive correlation with self-care management in patients with pulmonary tuberculosis (p= 0.000; r= 0,848).Conclusion: This study shows a strong correlation between the variables, whereas the higher the level of proactive coping, the better the self-care management in pulmonary tuberculosis patients. Further research can find out the factors that influence the proactive coping in pulmonary tuberculosis patients thus can improve the self-care behavior.

Drug adherence and efficacy of smear microscopy in the diagnosis of pulmonary tuberculosis after 2 months of medication in North-western Tanzania

OBJECTIVES

The study aimed at assessing the Tuberculosis (TB) medication adherence level and the efficacy of smear microscopy in the diagnosing pulmonary TB at month 2.

METHODS

A prospective study was conducted at the four sites located in the Northern-western Tanzania. New smear positive, pulmonary TB patients were followed up and their adherence to TB medication assessed after 2 months of the treatment. In addition, the acid fast bacilli (AFB) smear microscopy was performed after 2 and 5 months of the treatment. All smear positive samples were subjected to geneXpert (MTB/RIF) assay and culture on the Lowenstein Jensen (LJ) media.

RESULTS

A total of 331 smear positive, newly diagnosed patients with pulmonary TB were enrolled. The median age was 36 [Interquartile range (IQR): 28-45] years and males formed the slightly majority, 187 (56.5%) of the participants. A total of 105 (31.7%) patients were infected with HIV. Out of 331 patients, 36 (10.9%) were still AFB smear positive at the end of two month. Of these 19 (52.8%) were positive on GeneXpert MTB RIF and none was Rifampicin resistant. Of note, only 13 (31.1%) were culture positive (viable). None of the patients was positive at month 5. Poor adherence to TB medications in the first 2 months of treatment was observed in 56/331 (16.9%) [95% CI=12.9-21.0] of the patients.

CONCLUSION

Over two thirds of smear positive patients are wrongly put in one month extension of the intensive phase treatment; this may cause increased costs and drug toxicity. Culture should be advocated to confirm smear positivity after 2 months of medications. TB treatment drug adherence in our setting is good and is associated with successful cure. No multidrug resistant tuberculosis (MDR-TB) was observed. Continued surveillance and emphasizing of TB drug adherence should be kept upbeat in order to control tuberculosis in developing countries.

Experiences of patients having tuberculosis (TB) regarding the use of Directly Observed Treatment Short-Course (DOTS) in the North West Province, South Africa

BACKGROUND

Tuberculosis (TB) management remains a major challenge despite the implementation of Directly Observed Treatment Short-Course (DOTS). Some of the challenges include defaulting treatment, low TB cure rates and relapse after patients had been treated under DOTS.

OBJECTIVES

This study explored and described experiences of patients having TB regarding the use of DOTS in Doctor Ruth Segomotsi Mompati District of North West Province, South Africa. The study describes and recommends support required by patients having TB who are using DOTS.

METHODS

A qualitative, exploratory, descriptive and contextual design was used. The population consisted of all patients having TB under DOTS who had taken treatment for 2 months and more in one of the community health centres in Doctor Ruth Segomotsi Mompati District. Purposive sampling technique was applied to select participants receiving DOTS service. In-depth unstructured individual interviews were conducted, and data saturation occurred after having interviewed 15 participants. Ethical considerations were ensured throughout the study, and data were analysed using Tesch's method of coding and analysis.

RESULTS

Two themes emerged from data and these are discussed as concerns related to ineffective use of DOTS and lack of resources as contributory factor to ineffective use of DOTS. Among other categories, poor nurse-patient relationships and difficulties in accessing the community health centre emerged as consistent themes related to default and inconsistent use of DOTS.

CONCLUSION

Ineffective use of DOTS contributed to TB treatment default and low cure rate. Therefore, recommendations focused on strengthening effective use of DOTS for the management of TB.

A randomized controlled study comparing community based with health facility based direct observation of treatment models on patients' satisfaction and TB treatment outcome in Nigeria

BACKGROUND

Directly observed treatment short-course (DOTS) strategy is an effective mode of treating TB. We aimed to study the cost effectiveness and patients' satisfaction with home based direct observation of treatment (DOT), an innovative approach to community-based DOT (CBDOT) and hospital based DOT (HBDOT).

METHODS

A randomized controlled trial involving 150 newly diagnosed pulmonary TB patients in four TB clinics in Ile Ife , Nigeria, was done. They were randomly assigned to receive treatment with anti TB drugs for the intensive phase administered at home by a TB worker (CBDOT) or at the hospital (HBDOT). Outcome measures were treatment completion/default rates, cost effectiveness and patients' satisfaction with care using a 13 item patients satisfaction questionnaire (PS-13) at 2 months. This trial was registered with pactr.org: number PACTR 201503001058381.

RESULTS

At the end of intensive phase, 15/75 (20%) and 2/75 (3%) of patients in the HBDOT and CBDOT, respectively had defaulted from treatment, p= 0.01. Of those with pretreatment positive sputum smear, 97% (68/70) on CBDOT and 54/67 (81%) on HBDOT were sputum negative for AFB at the end of 2 months of treatment, p=0.01. The CBDOT method was associated with a higher patient satisfaction score compared with HBDOT (OR 3.1; 95% CI 1.25-7.70), p=0.001.The total cost for patients was higher in HBDOT (US$159.38) compared with the CBDOT (US$89.52). The incremental cost effectiveness ratio was US$410 per patient who completed the intensive phase treatment with CBDOT.

CONCLUSIONS

CBDOT is a cost effective approach associated with better compliance to treatment and better patient satisfaction compared to HBDOT.

Non-adherence to anti-tuberculosis treatment and determinant factors among patients with tuberculosis in northwest Ethiopia

Background

Non-adherence to anti tuberculosis treatment is one of the crucial challenges in improving tuberculosis cure-rates and reducing further healthcare costs. The poor adherence to anti-tuberculosis treatment among patients with tuberculosis is a major problem in Ethiopia. Hence, this study assessed level of non-adherence to anti-tuberculosis therapy and associated factors among patients with tuberculosis in northwest Ethiopia.

Methods

An institution based cross-sectional survey was conducted among tuberculosis patients who were following anti-tuberculosis treatment in North Gondar zone from February 20 – March 30, 2013. Data were collected by trained data collectors using a structured and pre-tested questionnaire. Data were entered to EPI INFO version 3.5.3 and analyzed using statistical package for social sciences (SPSS) version 20. Multiple logistic regressions were fitted to identify associations and to control potential confounding variables. Odds ratio (OR) with 95% confidence interval was calculated and p-values<0.05 were considered statistically significant.

Results

A total of 280 tuberculosis patients were interviewed; 55.7% were males and nearly three quarters (72.5%) were urban dwellers. The overall non-adherence for the last one month and the last four days before the survey were 10% and 13.6% respectively. Non-adherence was high if the patients had forgetfulness (AOR 7.04, 95% CI 1.40–35.13), is on the continuation phase of chemotherapy (AOR: 6.95, 95% CI 1.81–26.73), had symptoms of tuberculosis during the interview (AOR: 4.29, 95% CI 1.53–12.03), and had co-infection with HIV (AOR: 4.06, 95% CI 1.70–9.70).

Conclusions

Non-adherence to anti-tuberculosis treatment was high. Forgetfulness, being in the continuation phases of chemotherapy, having symptoms of tuberculosis during the interview, and co-infected with HIV were significantly associated with non-adherence to anti-tuberculosis therapy. Special attention on adherence counseling should be given to symptomatic patients, TB/HIV co-infected patients, and those in the continuation phase of the tuberculosis therapy.

Patient satisfaction on tuberculosis treatment service and adherence to treatment in public health facilities of Sidama zone, South Ethiopia

Background

Patient compliance is a key factor in treatment success. Satisfied patients are more likely to utilize health services, comply with medical treatment, and continue with the health care providers. Yet, the national tuberculosis control program failed to address some of these aspects in order to achieve the national targets. Hence, this study attempted to investigate patient satisfaction and adherence to tuberculosis treatment in Sidama zone of south Ethiopia.

Methods

A facility based cross sectional study was conducted using quantitative method of data collection from March to April 2011. A sample of 531 respondents on anti TB treatment from 11 health centers and 1 hospital were included in the study. The sample size to each facility was allocated using probability proportional to size allocation, and study participants for the interview were selected by systematic random sampling. A Pre tested, interviewer administered questionnaire was used to collect the data. Collected data was edited, coded and entered to Epi data version 3.1 and exported to SPSS version 16. Confirmatory factor analysis was done to identify factors that explain most of the variance observed in most of the manifested variables. Bivariate and Multivariate analysis were computed to analyze the data.

Result

The study revealed 90% of the study participants were satisfied with TB treatment service. However, 26% of respondents had poor adherence to their TB treatment. Patient perceived on professional care, time spent with health care provider, accessibility, technical competency, convenience (cleanliness) and consultation and relational empathy were independent predictors of overall patient satisfaction (P < 0.05). In addition to this, perceived waiting time was significantly associated with patient satisfaction (Beta = 0.262). In multivariate analysis occupational status, area of residence, perceived time spent with health care provider, perceived accessibility, perceived waiting time, perceived professional care and over all patient satisfaction were significantly associated with adherence to TB treatment (P < 0.05). Moreover, patient waiting time at reception room (Adjusted OR = 1.022, 95% CI 1.009, 1.0035) and Patient treatment phase (Adjusted OR = 0.295, 95% CI 0.172, 0.507) were independent predictor of adherence to TB treatment.

Conclusion

The finding of this study showed that patients’ perceptions on health care provider interaction had a significant influence on patient satisfaction and adherence to TB treatment. Moreover, absence of drugs and long waiting time had a negative outcome on patient adherence. Therefore, the problem needs an urgent attention from programme managers and health care providers to intervene the challenges.