Adherence to tuberculosis treatment among patients attending national tuberculosis elimination centre in tertiary care hospital, Bangalore

INTRODUCTION

Out of the causes of death worldwide, tuberculosis is the most common communicable disease. Mycobacterium tuberculosis, a tubercle bacillus is the cause for tuberculosis in humans. Many causes, such as the pandemic, poor nutrition, overcrowding, unhygienic living conditions, drug barons, and alcoholics, are to be blamed for the recurrence of tuberculosis.¹ Globally, tuberculosis claimed 1.6 million lives in 2021; it ranks as the second most common cause of infection after COVID-19 and the 13th major cause of mortality overall.² Globally, 10.6 million cases of tuberculosis were reported in 2021. India’s incidence of tuberculosis for the year 2021 is 210 per 100,000 people, an 18% decrease from the baseline year of 2015. According to these data, India ranks 36^th in terms of incidence rates.³ Following the World Health Organization (WHO) declaring TB as a ‘global emergency’ in 1993, the Government of India (GoI) launched the Revised National TB Control Programme (RNTCP) in 1997 based on WHO endorsed directly observed treatment short course (DOTS) strategy. RNTCP was expanded in a phased manner to achieve complete population coverage by 2006, with an overarching objective to detect at least 70% of sputum positive pulmonary TB cases and to achieve a cure rate of at least 85%.⁴ In 2014, the world health assembly unanimously approved to end global TB epidemic by “end TB strategy” a 20-year programme with vision of a world with zero death, disease and suffering due to TB. In view of End TB targets, the programme has been renamed from Revised National Tuberculosis Control Programme (RNTCP) to National Tuberculosis Elimination Programme (NTEP).⁵

The degree to which a patient takes their medication as directed by their doctor and as specified in their treatment plan is known as medication adherence. Treatment for tuberculosis, a chronic infectious disease that can be spread by droplets from individuals who have active pulmonary tuberculosis and its treatment involves a 6-9-month medication regimen with combinations of drugs, which may cause side effects and non-adherence. Inadequate adherence to TB medicine can provide special challenges as it may lead to treatment prolongation, increased expenses, a rise in new cases, and the emergence of multidrug resistance.⁶ One of the main causes of high death rates in the public health sector is tuberculosis. Since the start of the AIDS epidemic, the prevalence of tuberculosis in adults has more than doubled, with the majority of cases being associated with HIV/AIDS disorders. The number of cases of tuberculosis has risen to more than 500 per 100,000 people due to the AIDS epidemic that has struck the nation.⁷ A formal self-report measure of medicine taking behaviour is the eight-item Morisky medication adherence scale. It was created using a four-item scale that had already been validated and supplemented with additional items addressing the circumstances surrounding adherence behaviour.⁸

Hence the present study was conducted to find out the factors influencing adherence to tuberculosis treatment in a national tuberculosis elimination program center in Rajarajeswari medical college and hospital (tertiary care hospital), Bangalore.

Aim

To assess the adherence to tuberculosis treatment among patients attending NTEP centre in a tertiary care hospital, Bangalore

Objectives

To describe the socio demographic profile of tuberculosis patients. To assess the tuberculosis treatment adherence among patients. To identify the factors influencing adherence to treatment among tuberculosis patients.

METHODS

Study design

Cross sectional descriptive study design was employed in this study.

Sample size determination

A minimum sample size of 60 was calculated using Yamane equation

n= sample size, N = known population size, average number of patients attending NTEP unit =10/month, therefore for 7 months =10×7 =70 patients, e=margin of error = 0.05 (95% confidence level).

N= 10×7 =70,

e= 0.05

=70/1.17

= 59.829 =60

Inclusion criteria

Pulmonary and extra pulmonary tuberculosis patients registered and attending NTEP centre at Rajarajeswari Medical College and Hospital, Bangalore.

Exclusion criteria

Patients who have not given consent and those who were not traceable.

Sampling technique

Purposive sampling technique was employed.

Methodology

60 TB patients were selected for the present study based on inclusion and exclusion criteria. The information regarding tuberculosis treatment adherence was obtained from the tuberculosis (pulmonary and extrapulmonary) patients who were diagnosed and registered in NTEP centre, between May 2022-November 2022 through telephonic conversation with the patients and also by going through the documented evidence from the registers. Information was collected using validated 8 item self-report Morisky medication adherence scale which was entered in predesigned and pretested proforma.

Adherence was defined as self-report of having completed TB treatment plus documented evidence from the TB register of having completed treatment regimen as prescribed by the clinician. Standard Tb treatment requires patients to take a complex combination of drugs for 2 months in intensive phase and 4 months in continuation phase for new patients.⁹ Old TB cases were those who were discontinued on treatment and were put on treatment for 9-11 months.

Data analysis

Data were entered into Microsoft excel version for analysis. Descriptive statistics like mean and SD, inferential statistics like chi- square test was performed to determine the association between variables and potential factors that could influence adherence to TB treatment respectively. At a 95% level of confidence interval, p value of less than 0.05 was considered statistically significant.

Ethical consideration

Ethical clearance was obtained from the institutional ethics committee.

RESULTS

Age

Out of 60patients, majority i.e. 18(30%) were in the age group of 25-34 years, next highest i.e. 11 (18.33%) were in the age group of 15-24 years and 45-54 years respectively. Least i.e. 2 (3.33%) were in the age group of less than 15 years.

Gender

Out of 60 patients, 36 (60%) were males and 24 (40%) were females.

Educational status

Majority i.e. 21 (35%) were studied up to post high school diploma, next highest i.e. 18 (30%) patients were illiterate and least i.e. 1 (1.67%) patient studied up to high school certificate and professional course.

Occupation

Out of 60 patients, majority i.e. 31 (51.67%) were unemployed. Next highest 14 (23.33%) were semi skilled and least was 1 (1.67%) was professional.

Marital status

Majority i.e. 48 (80.00%) were married, 5 (8.33%) were unmarried, 4 (6.67%) were divorced and 3 (5.00%) were single.

Type of family

Majority i.e. 42 (70.00%) were from nuclear family and remaining 18 (30%) were from joint family.

Religion

Out of 60 patients, majority i.e. 54 (90.00%) were Hindus, 4 (6.67%) were Christians and 2 (3.33%) were Muslims.

Socio economic status

Majority i.e. 24(40.00%) were from lower middle class, next highest 19 (31.67%) were from middle class and least 1 (1.67%) was from upper class (Table 1).

Co morbidities among tuberculosis patients

Out of 60 patients, 4 patients (6.67%) had diabetes mellitus and only 1 (1.67%) patient was HIV reactive.

Out of 60 patients, 24 (40.00%) had substance abuse, out of them 13 (21.67%) were using both tobacco and alcohol, 7 (11.67%) were consuming only tobacco and the remaining 4 were (6.67%) consuming only alcohol (Table 2).

Out of 60 patients, 54 (90.00%) were new TB patients and remaining 6 (10.00%) were old TB patients.

Out of 60 patients ,49 (81.67%) had pulmonary TB, and 11 (18.33%) had extra pulmonary TB. Out of them, 5 (8.33%) had pleural effusion and 5 (8.33%) had cervical lymph nodes and 1 (1.67%) had TB bone and joints (Table 3).

Majority i.e.; 50 (83.34%) patients had cough, remaining 5 (8.33%) each had cough with fever and cough with weight loss as their common symptom respectively (Table 4).

Out of 60 patients, 41 (68.33%) Patients were adherent to treatment and the remaining 19 (31.67%) patients were not adherent to treatment.

DISCUSSION

In the present study, among 60 patients 30% were in the age group of 25-34 years, which differs from the study conducted by Dogah et al where 33.6% were in the age group of 30-39 years.¹⁰ In the study conducted by Yadhav et al where majority of participants i.e. 52.2% were in the age group of 15-40 years.¹¹ In the study conducted by Ubajaka et al mean age of respondents was 36.1±13.3 years.¹² In the present study 60% were males, this was in accordance with study conducted by Woimo et al, Yadhav et al Bagchi et al where 53.6%, 65% and 64% were males respectively.^9,11,13 It differs from the study conducted Ubajake et al where most of the respondents i.e.58.1% were females.¹² In the present study 35% were studied up to post high school diploma which differs from the study conducted by Ubajaka et al and Dogah et al where 41.9% and 42.2% had primary education respectively.^10,12 In the present study majority i.e. 90% were Hindus, this was in accordance with the study conducted by Yadhav et al and Bagchi et al where majority i.e. 82.8% and 80% were Hindus.^11,13 But differs from the study conducted by Dogah et al where majority i.e. 79.2% were Christians.¹¹ In the present study, majority i.e. 51.67% were unemployed, this differs from the study conducted by Yadhav et al and Gopi et al where 26.7% and 35% were unemployed.^11,14 In the present study 80% were married ,this was in accordance with the study conducted by Yadhav et al where 71.7% were married.¹¹ In the present study, 70% were from nuclear family, this differs from the study conducted by Yadhav et al where 52.8% belonged to nuclear family.¹² In the present study 1.67% of patients HIV reactive, this differs with the study conducted by Ubajaka et al where 28.1% of patients taking anti-retroviral drugs in addition to anti TB medications.¹²

In the present study medication adherence rate for tuberculosis was 68.33%which was lower than the study conducted by Eyramdogah et al, Yadav et al, Ubajaka et al, Bagchi et al where the adherence rate was 81.6%, 79.4%, 74.2% and 84% respectively.^10-13 In the present study, in the age less than 45 years, 40% were adherent 25% were not adherent. This differs from the study conducted by Widjanarko et al where in less than 40 years of age, 53% were adherent and 50% were not adherent.¹⁵

In the present study, among new TB patients 58.33% were adherent and 31.66% were not adherent. This differs from the study conducted by Widjanarke et al where among new TB patients 87% were adherent and 50% were not adherent.¹⁵ In the present study where majority i.e. 81.67% were pulmonary TB patients. This was in accordance with the study conducted by Woimo et al where majority of participants i.e. 60.2% were pulmonary TB patients.⁹ In the present study patients consuming alcohol 5% were adherent. This differs from the study conducted by Woimo et al where 57.9% of alcohol consuming patients were adherent.⁹

In the present study non adherence was 31.66% which was higher than the study conducted by Weiguo et al where non adherence to tuberculosis treatment was only 12.2%.¹⁶ In the study conducted by Gopi et al non adherence to tuberculosis treatment was 33%.¹⁴ In the study conducted by Santha et al, among new smear positive patients 17% were defaulted treatment.¹⁷

CONCLUSION

In this study adherence to tuberculosis treatment was 68.33%. There was no significant association between age, education, occupation, type of family, socioeconomic status, health status, personal habits, current TB status, type of TB, symptoms, personal habits and adherence to the tuberculosis treatment.

Recommendations

We recommend intensified health education and follow up and monitoring of patients for better adherence.

ACKNOWLEDGEMENTS

We wish to thank medical officer and lab technician at the NTEP centre for their assistance and cooperation for data collection.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Bello SI, Itiola OA. Drug adherence amongst tuberculosis patients in the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Afr J Pharm Pharmacol. 2010;4(3):109-14.
2. 2. Tuberculosis (TB). World Health Organization. Available from: https://www.who.int/news-room/fact-sheets/detail/tuberculosis#:~:text=In%202021%2C%20an%20estimated%2010.6,TB%20is%20curable%20and%20preventable. Accessed on 9 July 2023.
3. 3. Global Tuberculosis report 2022. World Health Organization; 2022. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports. Accessed on 9 July 2023.
4. 4. Yellappa V, Lefèvre P, Battaglioli T, Narayanan D, Van der Stuyft P. Coping with tuberculosis and directly observed treatment: a qualitative study among patients from South India. BMC Health Serv Res. 2016;16:1-1.
5. 5. Park K. Park’s textbook of Preventive and Social Medicine.23rd edn. India: Bhanot Publishers; 2015.
6. 6. Xu M, Markström U, Lyu J, Xu L. Detection of low adherence in rural tuberculosis patients in China: application of Morisky medication adherence scale. Int J Environ Res Public Health. 2017;14(3):248.
7. 7. Kaona FA, Tuba M, Siziya S, Sikaona L. An assessment of factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment. BMC Public Health. 2004;4(1):1-8.
8. 8. De las Cuevas C, Peñate W. Psychometric Properties of the eight-item Morisky medication adherence scale (MMAS-8) in a psychiatric outpatient setting. Int J Clin Health Psychol. 2015;15(2):121-9.
9. 9. Woimo TT, Yimer WK, Bati T, Gesesew HA. The prevalence and factors associated for anti-tuberculosis treatment non-adherence among pulmonary tuberculosis patients in public health care facilities in South Ethiopia: a cross-sectional study. BMC Public Health. 2017;17(1).
10. 10. Dogah E, Aviisah M, Kuatewo DA, Kpene GE, Lokpo SY, Edziah FS. Factors Influencing Adherence to Tuberculosis Treatment in The Ketu North District of the Volta Region, Ghana. Tuberculosis research and treatment. 2021;30:2021.
11. 11. Yadav RK, Kaphle HP, Yadav DK, Marahatta SB, Shah NP, Baral S, et al. Health related quality of life and associated factors with medication adherence among tuberculosis patients in selected districts of Gandaki Province of Nepal. J Clin Tubercul Other Mycobact Dise. 2021;23:100235.
12. 12. Ubajaka CF, Azuike EC, Ugoji JO, Nwibo OE, Ejiofor OC, Modebe IA, et al. Adherence to drug medications amongst tuberculosis patients in a tertiary health institution in South East Nigeria. Int J Clin Med. 2015;06(06):399-406.
13. 13. Bagchi S, Ambe G, Sathiakumar N. Determinants of poor adherence to anti-tuberculosis treatment in Mumbai, India. Int J Prevent Med. 2010;1(4):223.
14. 14. Gopi PG, Vasantha M, Muniyandi M, Balasubramanian R, Narayanan PR. Risk factors for non-adherence to directly observed treatment (DOT) in a rural tuberculosis unit, South India. Indian J Tubercul. 2007;54(2):66-70.
15. 15. Widjanarko B, Gompelman M, Dijkers M, van der Werf MJ. Factors that influence treatment adherence of tuberculosis patients living in Java, Indonesia. Patient Prefer Adhere. 2009:231-8.
16. 16. Xu W, Lu W, Zhou Y, Zhu L, Shen H, Wang J. Adherence to anti-tuberculosis treatment among pulmonary tuberculosis patients: a qualitative and quantitative study. BMC health services research. 2009 Dec;9:1-8.
17. 17. Santha T, Garg R, Frieden TR, Chandrasekaran V, Subramani R, Gopi PG, et al. Risk factors associated with default, failure and death among. Risk. 2002;62:10.