Published in IJCP March 2021
Retrospective Study
Reasons for Default among Patients Receiving Antitubercular Treatment in Eastern Uttar Pradesh
March 12, 2021 | Praveen B Gautam, Hn Chaudhary
     


Abstract

Objective: To study the reasons for nonadherence to antituberculosis treatment (ATT) in Eastern Uttar Pradesh. Methods: This retrospective analysis was done among a cohort of 670 patients attending BRD Medical College, Gorakhpur, Uttar Pradesh during 2014. Defaulters were interviewed using semi-structured questionnaire to elicit reasons of treatment default. Statistical analysis was done by using Chi-square test. Results: Out of the total 670 patients enrolled in the study, 87 (16.35%) pulmonary, 7 (6.08%) extrapulmonary and 2 (8.69%) both pulmonary as well as extrapulmonary, defaulted ATT. Overall default rate was 14.32%. Major reasons for treatment interruption were early improvement (24.19%), high cost of treatment (16.12%) and ATT-induced side effects (11.29%). Maximum treatment interruption occurred between second and third month of ATT. More than one reason was often reported for discontinuation of treatment. Conclusion: Noncompliance was found to be mainly due to early improvement, high cost of treatment and side effects of medicine. So, information on disease and treatment should be intensified and appropriate to the level of education of population, in order to promote adherence to treatment and counter the spread of multidrug-resistant tuberculosis.

Keywords: Noncompliance, antituberculosis treatment

Tuberculosis (TB) is a major public health concern in the South-East Asia region, with the region accounting for 39% of the global TB burden in terms of incidence. India alone accounts for 26% of the global TB burden. India is the second-most populous country in the world and is home to a quarter of the global TB cases annually. Of the estimated global annual incidence of 8.6 million TB cases in the year 2012, 2.3 million cases were estimated to have occurred in India.

World Health Organization (WHO) has recommended Directly Observed Treatment, Short-course (DOTS) strategy for global TB control, which is accepted worldwide. Direct observation and regular home visit by treatment providers are provisions to increase treatment completion under DOTS. Based on DOTS strategy, India’s Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997. Though treatment completion rate reported by RNTCP is satisfactory, recently there is growing concern of emergence of drug-resistant strains of TB bacillus. Incomplete antituberculosis treatment (ATT) is the reason for emergence of multidrug-resistant (MDR) strains of TB bacillus that emerged in the early 1990s. Extensively drug-resistant (XDR) strains emerged in 2006 and totally drug-resistant strains emerged in 2011 in India.

Further poor adherence to treatment leads to emergence of MDR bacilli. So, ensuring compliance is of utmost importance to control TB and halt the MDR-TB epidemic at its beginning. There is continuing need to sustain and further intensify the action being undertaken to reduce default. The focus must remain on dealing with important reasons of default and timely retrieval of patients who interrupt treatment. The aim of this study was to determine the reasons for nonadherence to ATT in Eastern Uttar Pradesh.

METHOD

The present study was conducted over a 6-month period from March to August 2014 and consists of an analysis of the data of pulmonary as well as extrapulmonary TB patients, indoor and outdoor, of BRD Medical College, Gorakhpur, Uttar Pradesh. After obtaining consent, patients were interviewed using a semi-structured questionnaire. Information recorded in the questionnaire included personal data, socio-demographic data, past and present history of ATT and reasons for discontinuation of ATT.

Definition Defaulter: As per RNTCP guidelines, defaulter is defined as a patient who has not taken antitubercular drugs for 2 or more consecutive months, any time after registration.

Patients who gave a history of treatment interruption as defined above were enrolled for the study. All these patients were then interviewed in detail using a pre-tested semi-structured questionnaire. In addition to the personal and socio-demographic data, treatment history was recorded in detail.

Statistical analysis was performed by using the Chi-square test and a ‘P’ value of <0.05 was considered as significant.

RESULT

The study was conducted among patients of BRD Medical College, Gorakhpur, Uttar Pradesh, who were admitted and attended OPD in the Dept. of TB and Chest. A total 670 patients suffered from TB. Among the 670 TB patients, 96 (14.32%) were found to have history of ATT interruption and were included in study. Biosocial characteristics of the patients were studied and the effect of various factors on patients’ compliance to treatment was observed.

In the present study, 78 (16.95%) males and 18 (8.5%) females defaulted. The highest number of defaulter were in the age group of 25-45 years [69 (18.15%)] while 15 (11.71%) defaulted in the age group of >45 years. In all, 12 (7.4%) defaulted in age group of below 25 years (Table 1).

Table 1. Factors Associated with Noncompliance to Treatment

Factors

Total no. of patients
(n = 670)

Non-compliance (%) n = 96

P value

Age (years)

<25

25-45

>45

Sex

Male

Female

Religion

Hindu

Muslim

Others

Marital status

Married

Others

Education level

Illiterate

Literate

Smoking

Smokers

Ex- or nonsmokers

Occupation

Employed

Laborer

House wives

Unemployed

Type of disease

Pulmonary

Extrapulmonary

Both

162

380

128

460

210

512

130

28

262

408

260

410

215

455

68

276

180

146

532

115

23

12 (7.40)

69 (18.15)

15 (11.71)

78 (16.95)

18 (8.5)

76 (14.84)

16 (12.30)

4 (14.28)

34 (12.97)

62 (15.19)

59 (22.69)

37 (9.0)

35 (16.27)

61 (13.40)

5 (7.35)

58 (21.01)

15 (8.33)

18 (12.32)

87 (16.35)

7 (6.08)

2 (8.69)

<0.05

<0.05

NS

NS

<0.05

NS

<0.01

<0.05

On analyzing the religion, 76 (14.84%) Hindus and 16 (12.30%) Muslims defaulted, while among others (i.e., Christian, Sikh), 4 (14.28%) defaulted. Analysis of marital status revealed that 34 (12.97%) married patients had history of treatment interruption while among others (unmarried, widow, divorced), 62 (15.19%) patients defaulted.

On analyzing the effect of education and occupation level, 59 (22.69%) illiterate and 37 (9.0%) literate patients had history of noncompliance to treatment, while 58 (21%) laborers, 18 (12.32%) unemployed, 15 (8.33%) house wives and 5 (7.3%) employed defaulted.

On analyzing the effect of smoking, 35 (16.27%) patients defaulted who were smokers while 61 (13.4%) patients defaulted, who were nonsmokers.

Among 670 patients, 87 (16.35%) pulmonary, 7 (6.08%) extrapulmonary and 2 (8.69%) both pulmonary as well as extrapulmonary patients defaulted. Eighty-one of the patients interviewed had no comorbidities and among the remaining 15 patients had history of comorbidities (e.g., diabetes mellitus, hypertension).

Among the 96 patients interviewed, 51 (53.12%) had defaulted treatment only once and 32 (33.3%) had interrupted treatment twice, while rest of patients had interrupted treatment more than two times (i.e., three or four). Thus, the 96 patients included in the study had interrupted treatment 157 times. Among 157 treatment interruption episodes, 102 (64.96%) occurred when the prescribing source of ATT was private practitioner, 50 (31.84%) took place while on treatment under DOTS therapy and remaining 5 (3.18%) interruptions took place while on non-DOTS treatment from a Government source.

Among the 96 patients interviewed, 38 (39.58%) stated only one reason for defaulting their treatment, 34 (35.4%) patients stated two reasons and 16 (16.66%) and 8 (8.33%) gave three and four reasons, respectively. Thus, 186 reasons for treatment interruption were obtained from 96 patients.

Maximum interruptions were found to occur between second and third month of ATT and 61 (64%) had defaulted treatment by the end of second month.

On analyzing the reasons of default among defaulters (Table 2), early improvements following medications were found to be the most common reason 45 (24.19%). Next important reasons were high cost of treatment and ATT-induced side effects (16.12% and 11.29%, respectively).

Table 2. Reasons for Default (186)

Reasons

No. of patients who interrupted treatment (n = 186)

Percentage (%)

Early improvement

45

24.19

High cost of treatment

30

16.12

ATT-induced side effect

21

11.29

Alcoholism

20

10.75

No improvement or deterioration

16

8.6

Advised to stop treatment by physician

13

6.98

Unaware about long duration of treatment

12

6.45

Long distance travel to center

11

5.91

Lack of faith in treatment

8

4.30

Personal reasons

a. Family problem

b. Went to village

10

6

4

5.37

3.22

2.15

Total

186

 

Alcoholism, no relief of symptoms and advised to stop by physician were other important reasons behind the default (10.75%, 8.6% and 6.98%, respectively). Some other reasons such as unaware about long duration of treatment, long distance travel to center, lack of faith and personal problem were also found to be important reasons for treatment interruption (6.45%, 5.91%, 4.30% and 5.37%, respectively).

DISCUSSION

Among the 670 TB patients, indoor and outdoor, during the study period, 96 (14.32%) had history of treatment interruption, of which 90.62% patients had pulmonary TB while 7.29% extrapulmonary and 2.08% had both pulmonary as well as extrapulmonary TB.

In the present study, out of 157 treatment interruptions, 102 (64.96%) interruptions occurred on private treatment, while 50 (31.84%) interruptions took place on DOTS and remaining 3.18% treatment interruptions occurred on non-DOTS government treatment. This emphasizes the need to provide DOTS to all as it is the only path to minimize treatment interruption.

In our study, default to treatment was found to be more in the 25-45 years age group of patients (18.15%), while good compliance to treatment was observed among less than 25 years (7.40% default). Similar results were also observed in a study conducted by Chandrasekaran et al where the odds of default were higher in those aged >45 years. In another study, Kumar et al observed maximum default in 35-44 years age group (25.4%), followed by the patients aged above 45 years (18.1%). Further, comparatively more default in the 25-45 years of age group is mainly due to the subjects being economically productive members of the family, which led them to the skip treatment rather than to leave their earning of the day.

Another risk factor for default is sex. Males defaulted more (16.95%) as compared to female (8.5%). More default among males is supposed to be due to being on job frequently; while in contrast, DOTS centers are present in most of the localities, so females can visit the center regularly. Similar results were also found in a study by Jaggarajamma et al in which male and female defaulters were 24% and 8%, respectively. 

Another risk factor for default is education. Illiterate defaulted more as compared to literate (22.69% vs. 9.0%). Similar results were also found in the study by Jaggarajmma et al.

Persons involved in various occupations, especially the laborer (21%), defaulted more as compared to housewives, unemployed (students, retired) and employed. Mittal et al observed that more people defaulted among businessman (30.6%), unemployed/retired (25%) and laborer (18.2%) groups. While few others did not find any association between patient’s occupation and response to treatment. The main reason behind the difference in compliance among persons with occupation seems to be loss of wages and lack of time.

In our study, 64% patients had interrupted treatment by the end of second month and other studies have also reported that maximum number of patients interrupted their treatment by the end of second or third month. Kaona et al reported up to 29.8% patients stopped taking their medication within the first 2 months of commencing treatment. Oliveira et al from Brazil found 43.3% of the defaulters in the first 2 months of treatment.

The present study identified early improvement following medication as the most common reason of default. So, the most common reason was a feeling of early improvement as stated by 45 patients (24.19%). Kaona et al also found that 29.8% of TB patients interrupted treatment once they start feeling better. In another survey by Tissera at Colombo Chest Clinic, relief from symptoms emerged as the most common reason for treatment interruption (13%).

The next most common reason for default was high cost of treatment cited by 30 (16.12%) patients in our study. This was exclusively reported by patients who took ATT from outside the government sources, i.e., purchased their medicine from the market. It is thus necessary that all TB patients should be registered under DOTS for treatment, so as to reduce the number of interruption occurring due to high cost of treatment.

Third common reason for default was ATT-induced side effects, in the present study, stated by 21 (11.29%) patients. Wares et al found the most common reason for stopping treatment being the adverse effects of ATT. A study from Bihar and West Bengal reported that improvement in symptoms (40% and 56%), intolerance to drugs (20% and 9%) and other illness causes in some patients. O’Boyle et al have also reported similar finding.

In the present study, 20 (10.75%) patients blamed alcoholism as the reason for their treatment interruption and 35 (16.27%) patients who smoked defaulted. Jakubowiak et al found alcohol use among the commonest reasons (30%) for treatment default. Sophia et al stated in their study that alcoholism can also predict poor treatment adherence.

Sixteen (8.6%) patients stopped treatment due to no improvement and 12 (6.45%) patients defaulted because they were unaware about long duration of treatment. Mittal et al have found similar finding.

Eleven (5.91%) patients had defaulted treatment due to long distance of travel to their DOTS center and 5.37% patients interrupted treatment due to personal reasons. In a study by Chatterjee et al, an important reason for default was distance from the treatment center. Mishra et al reported that the risk of nonadherence to treatment was significantly associated with cost of travel to the TB treatment facility.

CONCLUSION

There were many reasons reported for discontinuation of treatment and maximum interruption was found in the end of second and third month. The default could be a result of inadequate pre-treatment health education and counseling and poor defaulter tracing mechanism resulting from overworked healthcare personnel, feeling better after medication for a while and socioeconomic factors, including inadequate food and opportunity costs. Multiple factors influence default.

Keeping in mind all the important reasons of default, initial counseling by the health personnel explaining the treatment plan before starting of the treatment, periodic motivation of patient, increased number of DOTS centers and prompt action to tackle any problem will enhance compliance. Adequate health education and information about TB has been demonstrated to be most effective when given as one to one counseling. Such measures are likely to increase the therapeutic success rate, impacting on global disease burden attributable to TB and thus MDR-TB can be decreased. 

SUGGESTED READING

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