IAJPS 2018, 05 (10), 9970-9975 Rafia Jamil et al ISSN 2349-7750

CODEN [USA]: IAJPBB ISSN: 2349-7750

INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES
http://doi.org/10.5281/zenodo.1475281

Available online at: http://www.iajps.com Research Article

FACTORS CONTRIBUTING TO POOR COMPLIANCE WITH

ANTI-TB TREATMENT AMONG TUBERCULOSIS PATIENTS
1
Dr. Rafia Jamil, 1Dr. Mehreen Fatima Khan, 2Dr. Saba Ali
1
Mayo Hospital Lahore
2
Medical Officer, Kahna Nau Hospital (Managed by the Indus Hospital)
Abstract:
Tuberculosis (TB) has made a comeback. It has become a resurgent public health problem in developing countries
in the tropics and is the leading cause of death from any single infectious agent. Non-compliance to anti-
tuberculosis treatment is the most serious problem in TB control. A cross-sectional study was conducted to
investigate the determinants of poor compliance with anti-tuberculosis treatment among tuberculosis patients in
Gujranwala Pakistan in 2017. A total of 309 patients were included in the study of which 130 were tuber-culosis
patients who defaulted treatment and 260 were those compliant to treatment. Data col-lection was done by
interviewing the patients and collecting clinical and laboratory data from their medical records. Using multiple
logistic regression analysis, patients who were not on direct observed therapy (DOT) lived distant to the health
facility. Anti-TB treatment should be accessible to patients at the nearest health center from their residence.
Interventions with health education programs empha-sizing the benefits of treatment compliance should be
implemented by further large-scale multi-centered studies.
Corresponding author:
Dr. Rafia Jamil, QR code
Mayo Hospital,
Lahore

Please cite this article in press Rafia Jamil et al., Factors Contributing To Poor Compliance with Anti-TB
Treatment among Tuberculosis Patients., Indo Am. J. P. Sci, 2018; 05(10).

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INTRODUCTION: measures.
The World Health Organization (WHO) has declared
tuberculosis a global public health emergence (TB) MATERIALS AND METHODS:
(Kochi, 2007; WHO, 2008). The disease causes A cross-sectional study was conducted between June
significant mortality and morbidity globally and with and December 2017 at TB Clinic DHQ Hospital
the advent of the human immune deficiency virus Gujranwala Pakistan. The study population was TB
(HIV) epidemic, TB is regarded as a world-wide patients registered at the TB clinic, DHQ Hospital.
public health challenge (Kochi, 2007; WHO, 2008). All subjects were confirmed as TB patients by
The rising incidence of TB due to the effect of HIV clinical examination and laboratory investigations
in both developed and developing countries is well (sputum for acid fast bacilli positive status, chest X-
recognized (Narain et al, 2008). Besides well-known ray, Tuberculin test). Patients were referred by other
risk factors, the most important unresolved challenge health facilities if they were suspected of suffering
in TB control is the treatment completion. Treatment from TB and diagnosed and treated at the TB clinic.
will only be effective if the patient completes the Patients were ineligible for the study if they were too
regimen which includes a combination of drugs ill to be interviewed, were suffering from psychiatric
recommended by the physicians. Poor com-pliance illness and gave an incorrect address or could not be
contributes to the worsening of the TB situation by traced or died. There was no age exclusion.
increasing incidence and initiating drug resistance.
Resistance to anti-TB drugs has also emerged as an The frequency and duration of usual treat-ment for
important obstacle in the control of the disease. each patient at the chest clinic is determined by the
World-wide patient compliance with anti-TB therapy, physician. There were different treatment regimens
with an estimate of as low as 40% in devel-oping which consisted of a combination of two or three or
countries, remains the principle cause of treatment four standard anti-TB drugs namely streptomycin,
failure (Fox, 1983). The World Health Orga-nization isoniazid, rifampicin and pyrazinamide.
recommends at least 85% cure rate of all diagnosed
TB cases (WHO, 2002). In order to achieve this cure The definitions of compliance and non-compliance
rate, compliance needs to be in the order of 85-90 %. were determined by the Ministry of Health based on
World Health Organiza-tion guidelines. Compliance
It is therefore beneficial to study factors related to was defined as completion of prescribed treatment or
poor compliance, default and aban-donment of as missing less than 25% of treatment within the
treatment, which are responsible for drug resistance speci-fied duration. Patients who complied with
and increased incidence of TB. Factors that have treatment but had not completed the treatment course,
been reported as being associated with increased were also excluded from the study since their final
compliance by many studies were directly observed compliance status was yet tobe determined. The
therapy. compliant patients were recruited to the study only
when they came for follow-up one month after
In this regard, a study was conducted to assess non- completion of the course of treatment. They were
compliance and determine treat-ment-related factors, eligible to be included into study at the very first visit
disease related factors, knowledge and attitude for follow-up for clinical check-up and other
related factors and socio-demographic factors, which laboratory tests after treatment completion.
may have influenced the poor compliance of TB pa-
tients towards anti-TB treatment in Gujranwala Disease related factors were obtained by physician
Pakistan. Even though similar studies have been done during history taking and physical examination
in other parts of the world, there was still a need to sessions when patients were diagnosed as TB. The
conduct this study in this region as there are research team collected this information from
differences compared to other coun-tries in many medical records of patients. Two trained research
aspects such as culture, demog-raphy, socio- assistants conducted the interviews and completed
economic status, knowledge level, drugs used, the questionnaires for both compliance and non-
tolerance to the side effects of drugs. The results of compliance groups (for non- compliance group,
other studies may not be relevant to apply to the either at chest clinic or at their residence). The
context of this region. The expected benefits from responses from the patients who were younger than
conduct-ing this study included determining possible 15 years old were counterchecked by asking their
solutions to the existing treatment default problem, to accompanying parents or guardians. The re-sults of
help reduce the transmission and incidence of TB and laboratory investigations and other information were
to contribute towards the improvement of TB control also collected from the medical records of individual
programs especially in planning intervention patients.
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when contacted by phone. When home visits were

The questionnaire which had been pre-tested on 50 made, seven patients were not at home or did not
patients prior to data collection included the consent and 84
following variables: (1) socio-demographic and other
related factors such as age, gender, ethnicity, marital patients were willing to participate in the study.
status, educa-tional level, occupation, family income, Therefore finally, there were 130 non-compliant and
na-tionality, residential locality (urban/rural), (2) 260 compliant patients who were recruited to the
knowledge about TB and attitude towards anti-TB study giving the ratio of non-compliance to
treatment, (3) treatment related factors such as compliance as 1:2. The response rates for compliance
treatment regimen, knowledge about complete and non-com-pliance group were 87% and 60%
dosage of treatment, mode of therapy, side effects of respec-tively and it was statistically significantly
oral and parenteral drugs, problem with distance different (χ2=50.8, p<0.001). It showed that non-
between residence and treat-ment center, waiting compliant patients were more reluctant to participate
time, direct observed therapy (DOT) status, (4) in the study.
disease related factors such as site of tuberculosis
(pulmonary/extra-pulmonary), sputum smear result, Among 390 patients recruited to the study, mean age
severity of the disease, type of tuberculosis (first was 43±17 years with a range of 6 to 84 years. A
timediagnosis/relapse/multi-drug resistant tubercu- total of 66% of non-com-pliance group were males.
losis) and human immuno-deficiency virus (HIV) The Malay ethnic group was predominant comprising
carrier status, and (5) other risk factors such as BCG 94% of all patients. Site of the disease was predomi-
vaccination status, presence of BCG scar, smoking nantly pulmonary (89%) cases. Majority of patients
habit, alcohol intake, intravenous drug user (IVDU) fell into the category of mild and moderate severity
status, move-ment of residence during the course of of disease by X-ray find-ings. Among 63 intravenous
treat-ment and satisfaction with services and staff drug users, 11% were HIV positive (7 out of 63).
receptiveness towards patients. The question-naire
was constructed based on factors dem-onstrated On univariate analysis, there were no significant
previously to be related to non-compliance or differences in socio-demographic characteristics
considered to be clinically important. between non-compliance and compliance groups
(Table 1). Among attitude variables, health seeking
RESULTS: attitude towards treatment (over the counter
There were 709 TB patients who attended chest clinic treatment) was found of borderline significance
during study period. A total of 309 patients which was marginally better in compliance group
completed anti-TB treatment. Among the other 400 (Table 2). Among treatment related factors, there
patients, 237 were not compliant. A total of 58 were significant differences between compli-ance and
patients could not be recruited as they had died and non-compliance groups regarding convenience with
105 were still undergoing treatment and were clinic day schedule (those who were inconvenient
therefore ineligible for the study. Thus, the with schedule had about 2.5 times higher odds of
compliance rate was reported as 56.6% (309/546). being non-compliant), DOT (those who were not on
DOT had seven times higher odds of being non-
Among the compliant group, 299 patients were compliant), problem with distance to health facility
eligible for the study and when ap-proached, 260 (those who had problem with distance had two times
agreed to participate in the study. For 237 patients in higher odds of being non-compliant) and patients
non-compliance group, a total of 70 patients could be who lived more than ten kilometers away from health
re-trieved and among them, 51 were eligible for the facility had seven and half times significantly higher
study and when approached, 46 volun-teered to be odds of being non-compliant (Table 3). Disease
included in the study. Ineligibility of most of the related factors did not show any significant difference
patients in both groups was mainly because the between two groups (Table 4). Among other
patients were ill to be interviewed. Among 167 non- contributing factors, intravenous drug Knowledge
compliance patients who could not be retrieved, 26 and attitude factors contributing to poor
pa-tients gave wrong address and 50 patients could compliance with anti-TB treatment.
not be traced at home/ unwilling to accept home visit .

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Table 1
Socio - demographic factors contributing to poor compliance with anti-TB treatment
(Univariate analysis).

a
Variable Non-compliance Compliance Odds ratio LR
(n)(%) (n)(%) (95% CI) (p-value)

Sex Male 248 86 (66) 162 (62) 1 0.56 (0.456)

Female 142 44 (34) 98 (38) 1.18 (0.76-1.84)
Age group ?20 36 9 (7) 27 (10) 1 2.30 (0.890)
21-40 160 57 (44) 103 (40) 1.34 (0.54-3.29)
41-60 118 38 (29) 80 (31) 0.56 (0.21-1.51)
>60 76 26 (20) 50 (19) 0.86 (0.31-2.37)
Residence
Urban 151 51 (39) 100 (38) 1 0.02 (0.883)
Rural 239 79 (61) 160 (62) 0.97 (0.63-1.49)
Marital
status
Married 268 93 (72) 175 (67) 1 0.82 (0.664)
Never married 88 26 (20) 62 (24) 0.79 (0.47-1.33)
Widow / Divorce 34 11 (8) 23 (9) 0.90 (0.42-1.93)
Ethnic group
Malay 367 122 (94) 245 (94) 1 0.02 (0.880)
Chinese and Siamese 23 8 (6) 15 (6) 1.07 (0.44-2.60)
Level of Education
Tertiary and Secondary 213 70 (54) 143 (55) 1 0.16 (0.923)
Primary 118 41 (31) 77 (30) 1.08 (0.68-1.75)
Uneducated/not yet schooling 59 19 (15) 40 (15) 0.97 (0.53-1.80)
Occupation
Government Servant 41 12 (9) 29 (11) 1 12.28 (0.139)
Own business 25 9 (7) 16 (6) 1.46 (0.39-5.39)
Labourer+farmer 27 6 (5) 21 (8) 1.33 (0.36-4.87)
Housewife 83 30 (23) 53 (20) 1.62 (0.59-4.44)
Unemployed 68 28 (21) 40 (15) 2.43 (0.88-6.68)
Student 32 4 (3) 28 (11) 1.08 (0.30-3.92)
Retired 25 10 (8) 15 (6) 0.51 (0.09-2.73)
Others 89 31 (24) 58 (23) 0.91 (0.32-2.62)
Monthly average income
Low (< RM 1,000) 354 119 (92) 235 (90) 1 0.14 (0.709)
Middle and high (?RM 1,000) 36 11 (8) 25 (10) 0.87 (0.41-1.83)

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(Univariate analysis).

a
Variable Non-compliance Compliance Odds ratio LR
(n)(%) (n)(%) (95% CI) (p-value)

Causes of TB
Correct 215 74 (57) 141 (55) 1 0.95 (0.621)
Incorrect 43 16 (12) 27 (10) 1.13 (0.57-2.23)
Do not know 132 40 (31) 92 (35) 0.83 (0.52-1.32)
Spread of TB
Correct 296 102 (79) 194 (75) 1 1.05 (0.592)
Incorrect 13 3 (2) 10 (4) 0.57 (0.15-2.12)
Do not know 81 25 (19) 56 (21) 0.85 (0.50-1.44)
Prevention of TB
Correct 210 76 (68) 134 (57) 1 4.78 (0.092)
Incorrect 45 13 (12) 32 (13) 0.72 (0.35-1.45)
Do not know 92 22 (20) 70 (30) 0.55 (0.32-0.97)
Seriousness of TB
Yes 328 115 (89) 213 (82) 1 3.95 (0.139)
No 36 7 (5) 29 (11) 1.22 (0.51-2.88)
Do not know 26 8 (6) 18 (7) 0.54 (0.17-1.75)
Preventable
Yes 367 121 (93) 246 (95) - 1.42 (0.493)
No 5 1 (1) 4 (1) 0.51 (0.06-4.06)
Do not know 18 8 (6) 10 (4) 1.63 (0.63-4.23)
Curable
Yes 358 121 (93) 237 (91) 1 1.38 (0.503)
No 7 1 (1) 6 (2) 0.33 (0.04-2.74)
Do not know 25 8 (6) 17 (7) 0.92 (0.39-2.20)
Seeking treatment
Hospital 318 109 (84) 209 (80) 1 7.63 (0.054)
General practitioner 38 16 (12) 22 (8) 1.39 (0.70-2.77)
Traditional 5 1 (1) 4 (2) 0.48 (0.05-4.34)
Over counter 29 4 (3) 25 (10) 0.31 (0.10-0.90)
Disease related factors contributing to poor compliance with anti-TB treatment
(Univariate analysis).

a
Variable Non-compliance Compliance Odds ratio LR
(n)(%) (n)(%) (95% CI) (p-value)

Sputum smear
Positive 379 128 (98) 251 (97) 1 1.30 (0.255)
Negative 11 2 (2) 9 (3) 0.44 (0.09-2.05)
Site
Pulmonary 348 118 (91) 230 (88) 1 0.49 (0.483)
Extra-pulmonary 42 12 (9) 30 (12) 0.78 (0.39-1.58)
Severity (by x-ray)
Mild 221 71 (54) 150 (58) 1 3.37 (0.186)
Moderate 128 40 (31) 88 (34) 0.96 (0.60-1.53)
Severe 41 19 (15) 22 (8) 1.83 (0.93-3.59)
Diagnosis
First time diagnosed 353 118 (91) 235 (90) 1 0.02 (0.903)
Relapse 37 12 (9) 25 (10) 0.96 (0.47-1.97)
HIV status
Negative 272 122 (94) 250 (96) 1 1.01 (0.316)
Positive 18 8 (6) 10 (4) 1.64 (0.63-4.26)

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