Assess the knowledge and associated factors of DOTS defaulter among Tuberculosis clients

 

Dr. P. Mangala Gowri¹, Mrs. G. Bhuvaneswari², Mr. C. Manoj³, Mr. R. Varatharajan³, Ms. Subhashini³, Ms. Jomcy³, Ms. Epsimal³

¹Principal, Saveetha College of Nursing, Saveetha University, Chennai

²Assitant Professor, Saveetha College of Nursing, Saveetha University, Chennai

³B. Sc (Nursing IV Year), Saveetha College of Nursing, Saveetha University, Chennai

 

ABSTRACT:

Backgroud of the study : Tuberculosis is the second most important cause of adult death worldwide due to infectious disease, after HIV/AIDS. Roughly 13.2 million (new and old cases), new cases 9.2 million every year are affected globally. Aims and Objectives: 1.To assess the factors associated with the DOTS defaulter among TB clients at selected area. 2. 2. To associate the knowledge on control and prevention of tuberculosis among TB clients at selected area. Methods and material: The main aim of the study was to assess the factors associated with DOTS defaulter among TB clients at selected area. The study was a descriptive in nature 30 samples were selected by simple random sampling technique. The tool used for this study was structured questionnaire method on DOTS therapy among TB clients. The collected data were tabulated and analyzed by using descriptive and inferential statistics. Results:  The result reveals that out of 30 samples 15 members had moderate knowledge, 6 members had inadequate knowledge and 9 members had adequate knowledge and also the findings of the study revealed that there was a significant association between demographic variables. Conclusion: Despite meeting the WHO goals for default and treatment failure, it is important to aggressively address those aspects that can be changed so the country can continue to reduce the burden of TB on its community. Recommendations are made from the results of this study that may help improve adherence to DOTS programmes.

 

 

 

INTRODUCTION:

Tuberculosis is the second most important cause of adult death worldwide due to infectious disease, after HIV/AIDS. Roughly 13.2 million (new and old cases), new cases 9.2 million every year are affected globally. About one-third of the world’s population is infected with tuberculosis (TB)⁽¹⁾.  Approximately one in every 10 of these people will develop TB disease, which typically consists of a chronic cough, severe weight loss, night sweats and progressive, irreversible lung damage.⁽²⁾

 

Globally, the DOTS (Directly observed treatment, short course) strategy has been recognized as the best cost-effective approach to tuberculosis control, to reduce the disease burden and to reduce the spread of infection. DOTS is the only means by which a cure can also be ensured.⁽³⁾ The challenge is to expand the coverage of DOTS so that the most patients get effective treatment. There are more than 1 million TB patients who have no access to treatment throughout India, a quarter of whom live in North India. In the state of Delhi, where Operation ASHA's 34 DOTS centers currently serve 1,200 patients, there are nearly 20,000 more patients who still do not receive care⁽⁴⁾. India is the highest TB burden country in the world and accounts for nearly one-fifth that is 20 percent of the global burden of tuberculosis.

 

As per the WHO 2009 Global TB Control Report, TB mortality in the country has reduced by 43%, from an estimated 42/lakh population in 1990 to 24/lakh population in 2009, and the prevalence of TB in the country has reduced by 67%, from 568/lakh population in 1990 to 185/lakh population. Annual case detection rate for New Delhi was 296/100000 as compared to national average of 130/100000 and annual new smear positive case detection rate also was 87% well above the national average of 70% in 2007⁽⁵⁾.

 

The therapeutic regimens as recommended by the Revised National TB Control Programme (RNTCP) have been shown to be highly effective for both preventing and treating tuberculosis, but poor adherence to medication is a major barrier to its global control.

 

OBJECTIVES:

1      To assess the factors associated with the  DOTS defaulter among TB clients at selected area.

2      To associate the factors associated with their demographic variables among TB clients at selected area.

 

NEED FOR THE STUDY:

Successful treatment of tuberculosis involves taking anti tuberculosis drugs for at least six months. Tamil Nadu subscribes to the internationally accepted World Health Organization (WHO) strategy for TB control. Consequently, duration of treatment within the study period was either six or eight months. In the first two months of treatment (intensive phase), a combination dose of Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E) (2RHZE) was used daily followed by either 6 months of Ethambutol and Isoniazid (6EH) for the 8 month regime; or 4 months of rifampicin and isoniazid (4RH) for the 6 months regime. During the intensive phase of treatment, patients collect the drugs from facilities weekly while monthly collections are done during the continuation phase. The treatment regime for retreatment patients is 8 months and includes Streptomycin (S) in the first 2 months. Emphasis is made on Direct Observation of Treatment (DOT) by a health worker or other responsible persons, including household members or others with whom the patient has a close relationship, at least during the intensive phase of treatment. Some patients fail to adhere to treatment and eventually default before completing the course. Patients whose treatment  are interrupted for 2 consecutive months or more, as defined by WHO, are reported as ‘Out of Control’ at the end of  the treatment period. Poor adherence to treatment means that patients remain infectious for longer and are more likely to relapse or succumb to tuberculosis.⁽⁶⁾

 

 

A study conducted on quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts, revealed that out of 237 patients, 43% interrupted treatment for 15 days and 30% had at least 1 day's dose of TB drugs unused as the TB care providers were untrained (44%) and daily outpatient TB care was not given. In contrast, it happened as their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients’ minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses.  Study suggested for Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment. The treatment outcome ‘‘default’’ under RNTCP is a patient who has not taken anti-TB drugs for 2 months or more consecutively after starting treatment⁽⁷⁾. The public health and clinical consequences of TB treatment default are severe. Relative to those who complete treatment, patients who default may perpetuate TB transmission and have high post-treatment, mortality and rates of recurrent disease [4,5]. Among new patients, the proportion of patients who defaulted from RNTCP has been relatively low (8%). Risk factors for default among new patients have been reported in several studies from India^(8,9,10). Improving treatment outcomes and designing effective interventions require understanding of the factors that prevent people from adhering and those that help in treatment completion.  In India several social and economic factors such as low income, lack of social support, low education, financial problems and the inability to afford services [9,10] have been linked to TB treatment adherence. Older age, the male sex, inadequate knowledge, ignorance on the need for treatment compliance and stigma are among reported patient-related factors that influence default in the region^(11,12). This study aimed to determine the duration TB patients stayed in treatment before default and the factors associated with default in Specifically, we evaluated the timing of treatment default among those who abandoned treatment; we examined the risk factors for treatment default; and, through interviews involving both structured and open-ended questions, we explored the health attitudes and beliefs associated with treatment default^(13,14).

 

A 2007 study from Senegal by Thiam et al. demonstrated the effectiveness of an intervention package which included improved patient counseling, patient choice of DOT supporter, decentralization of treatment and reinforcement of supervision activities. The intervention was studied from 2003-2005. Treatment success rates were 88% in the intervention group as compared with 76% in the control group. Default rates were also reduced from 16% in the control group to 5.5% in the intervention group⁽¹⁵⁾.

RESEARCH METHODOLOGY:

Descriptive research design with one group pre-test method was chosen to assess the factors associates with DOT’S defaulter among tuberculosis clients. The setting of the study was conducted in and around the villages in Thiruvallu district. The study population comprised of the cohort of patients (adults and children) registered during the period January 20014 to March 20016 in 30 high-volume public TB treatment facilities. The target population of the study was  a Tuberculosis client between the age groups of above 25 years. After obtaining consent from the Panchayath officers the study was conducted at Kuthambakkam, Nemum, Avadi and Puthuchathiram, Andersonpet villages, etc.,  with  30 tuberculosis clients who met the inclusion criteria were selected by convenient sampling  technique. Data were collected by interview method on one to one basis. These included demographic data (age, sex, residence, marital status) and medical and treatment data (treatment observer, patient and TB types, HIV status, treatment regimen, sputum smear microscopy results, the date treatment was started and ended and the treatment outcome). To obtain primary data, the study samples were interviewed using a both open and close-ended structured questionnaire. Data on variables not routinely collected in treatment registers such as socioeconomic status, drug side effects, alcohol abuse and herbal medication use among others were collected. Also collected were data on factors pertaining to knowledge about TB transmission and duration of treatment. Confidentiality was maintained throughout the procedure. Collected data were analyzed by using descriptive and inferential statistics.

 

RESULTS AND DISCUSSION:

Among 30 cases who were sputum smear positive for Mycobacterium tuberculosis at the commencement of treatment, 36%, defaulted before bacteriological conversion was confirmed. Characteristics of the sample population. To enhance understanding of risk factors for default, a sample of 30 adults were randomly selected from the study population. All sampled controls were traced and participated in the interviews. Out of the 30 samples, interviewed, 14 (46.6%) had  age group of 46-50yrs, (90%) were male patients, (50%) were education primary, 53.3%  of defaulter is daily wages. Regarding the marital  status were single 4 (13.3%) were divorced 11(36.6%) were married 15(50%) and  40% of the clients were Middle class socioeconomic status, regarding  Duration of the resistance of treatment is (46.6%) were 5 years, regarding types of tuberculosis 73.3% were extra pulmonary tuberculosis clients. Regarding knowledge on tuberculosis among DOTS defaulter results shows that, out of 30 samples, 15(50%) had moderate knowledge, 6 (20%) had inadequate knowledge, 9(30%) adequate knowledge. The mean, standard division of the study were as follows 16 and 1.76. Risk factors for default Through an open ended question, patients who defaulted from treatment were asked to give one most important reason for their default.

 

Table1: Frequency and percentage distribution of demographic variables among the DOTS defaulter among TB clients at selected area.

DEMOGRAPHIC VARIABLE	FREQUANCY	PERCENT-AGE
1.Age a) 25-30yrs b) 35-45yrs c) 46-50yrs 2.Sex a) Male b) Female 3.Level of education a) Primary b) Secondary c) Illitrate 4.Occupation a) Business b) Daily wages c) None 5. Socio-economic status a) Lower-middle class b) Middle class c) Poor 6.Duration of resistance in treatment a) 3 years5years b) 4years c) 5years 7.Types of tuberculosis a) Extra pulmonary b) Pulmonary 8.Marrital status a) Single b) Divorced c) Married	6 10 14   28 2   15 4 11   2 16 12   10 12 8     6 10 14   22 8   4 11 15	20% 33% 46.6%   90.0% 10%   50% 13.3% 36.6%   6.6% 53.3% 40%   33.3% 40% 26.6%   20% 33.3% 46.6%   73.3% 26.6%   13.3% 36.6% 50%

 

Factors associate with  DOTS  Default:  Although the practice was non-systematic, reason for default during the present  treatment regimen was recorded on the TB treatment cards of 20 patients (64.4%). Amongst these 30 patients, the most commonly cited reasons were intensive phase (40%), maintenance phase (60%), lack of travel facility (40%)  lack of motivation (26%), relief from symptoms (migration 5 (16.6%), refusal 18 (60%), treatment from private sector 3 (1%), side effects  19(63%), substance abuse 2(0.6%). A non-experimental study was conducted to assess the factors associates with DOT’S defaulter among tuberculosis clients. A total of 30 subjects was selected from selected area by convenient sampling technique. A pre-structured and pre-tested format questionnaire was administered to the tuberculosis clients. Nearly 4/5^th (96%) of tuberculosis clients were aware of factors associates with DOT’S defaulter.

Table 2: Frequency and percentage distribution of knowledge on tuberculosis among DOTS defaulter

Knowledge	Inadequate knowledge		Moderate knowledge		Adequate knowledge		Mean	Stander deviation`
	No	%	NO	%	NO	%	16	1.76
The assess the knowledge on control and prevention of tuberculosis among DOT’S defaulter clients	6	20%	15	50%	9	30%

 

Table 3: Frequency and percentage distribution of factor associated with on DOTS defaulter among tuberculosis clients

S.NO	FACTORS ASSOCIATED WITH DOTS DEFAULTER	PERCENTAGE
1.	Phases of treatment a.        Intensive b.        Maintenance	40% 60%
2.	Reasons for default a.        Lake of Travel facility b.        Lack of motivation c.        Relief from symptoms d.        Fixed timing	40% 26% 23% 11%
3.	a.        Alcoholism b.        Smoking c.        Poor diet intake d.        Consequently forgetting to take drugs e.        Stigma f.          Unmarried g.        Migration h.        Refusal i.         Treatment from private sector j.         Side effects  k.        Substance Abuse	20% 15% 10% 25% 18% 12% 36% 60% 1% 63% 1%

 

CONCLUSION:

Defaulting from treatment is common among the large number of re-treatment patients in India. Default usually occurs early during treatment, particularly in the transition period from the Intensive phase  to Continous Phase  of treatment, and was fairly  associated with male sex, prior default, prior treatment from a private provider, and DOT from a public health facility. The smoking, Refusal, Migration, Lack of motivation, and drug side effects were significantly associated with defaulting. Efforts to improve pre-treatment counseling, increase the proportion of patients treated by community-based treatment providers, and strengthen retrieval.

 

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Accepted on 25.01.2018           © RJPT All right reserved

Research J. Pharm. and Tech 2018; 11(6):2313-2316.