1Demonstrator Department of Pharmacology, Government Medical College Kathua, (UT J and K), 184101, 2Department of Pharmacology, Government Medical College Kathua, (UT J and K), 184101, 3Department of Pharmacology, Government Medical College Kathua, (UT J and K), 184101, 4MBBS, Medical Officer in District Tuberculosis Centre Kathua (J and K), 184101
Received: 08 Nov 2020, Revised and Accepted: 10 Jan 2021
Objective: The objective of present study was to examine the non-adherence among tuberculosis patients to antitubercular drugs and the factors associated with non-adherence.
Methods: Prospective observational study was conducted in department of pharmacology Government Medical College, Kathua in collaboration with the district tuberculosis centre, Kathua for a period of four months. TB Patients on treatment for last 8 w were included in the study. The pre validated questionnaire was provided to patients and their responses were analysed. Morisky’s Medication Adherence Scale (MMAS-4) was used to assess adherence/non-adherence to antitubercular drugs.
Results: Total 72 patients were included in trial and out of which 60(83.33%) were males and12 (16.66%) were females and the maximum were between 40-50y (38%) of age, mostly illiterate (50%) and from lower socioeconomic status (38%). Out of 60 male patients, 48(80%) showed adherence to anti-tuberculosis drugs, while remaining 12(20%) were non-adherent. Whereas 10females (83%) were adherent and 2 (16.66%) were non-adherent. Forgetfulness (42%), followed by illiteracy (21.4%) and longer distance from health institute (14%) were main reasons for non-adherence.
Conclusion: Present study has shown non-adherence is maximum among males, illiterate, low socioeconomic group, longer distance from the health institution.
Keywords: Anti tubercular therapy, Adherence, Non-adherence
© 2021 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/)
DOI: https://dx.doi.org/10.22159/ijcpr.2021v13i2.41550. Journal homepage: https://innovareacademics.in/journals/index.php/ijcpr
Tuberculosis is an infectious disease caused by mycobacterium tuberculosis bacteria (MTB) and it generally affects the lungs (pulmonary tuberculosis), but other parts of body may also get involved (extra pulmonary tuberculosis) . It is transmitted by infected milk, meat and from person to person through droplet infection. Most of patients become fully non-infectious and cured with therapy if tuberculosis (TB) is detected early and treated .
TB can be prevented by screening of high risk cases, early detection and vaccination with the bacillus Calmette-Guérin (BCG) vaccine. High risk includes household, workplace, and social contacts of people with active TB [3–5]. In tuberculosis treatment, there is fixed dose combination of drugs which include isoniazid, rifampicin, pyrazinamide, ethambutol. These are first line drugs as recommended by WHO . Patients taking antitubercular drugs sometimes do not adhere to the treatment and this has become now a serious issue.
Non-adherence to TB treatment can cause delayed conversion of sputum to become negative, high relapse rate and emergence of drug resistance . The emergence and rapid growth of multidrug resistant (MDR TB) has become a matter of great concern .
Non adherence to antitubercular treatment has been a persistent problem throughout the world, including both developed and non-developing countries. Non adherence is mostly seen in alcoholic patient, low annual income, low literacy rates, longer duration of treatment and younger age group in developed or industrialised countries, whereas adherence was higher in patients who were initially hospitalised and returned for follow up within 4 w of initiation of therapy [9, 10, 16].
The aim of the current study was to evaluate and analyze the reasons of nonadherance among patients of tuberculosis on antitubercular treatment. Patients from district tuberculosis centre Kathua were included in study and centre it caters majority of patients from rural areas.
The main objective of this study is to evaluate the non-adherence to antitubercular drugs among TB patients.
To study the reasons for non-adherence
MATERIALS AND METHODS
This observational study was carried over for a period of 4 mo (September 2019-December 2019) in the department of pharmacology, Government Medical College Kathua in collaboration with district tuberculosis centre kathua, UT Jammu and Kashmir.
All tuberculosis patients who had completed at least 2 mo of antitubercular treatment and gave consent to participate.
Patients of both gender were included
Patients who were not willing to participate in the study and who were on antituberular for less than 8 w
Permission was obtained from the institutional ethical committee before starting of the study. Written consent was obtained from patients to confirm their willingness for participation after explaining the objective of study. All procedures followed in accordance with the Helsinki declaration of 1975.
The data was collected by face to face interview using a prevalidated-questionnaire. The questionnaire was prepared which include sociodemographic profile (name, age, sex, address, education, level of income, travelling distance to hospital), Personal habits (Alcoholic, Smokers), medical history (Diabetic, HIV).
Morisky’s medication adherence scale (MMAS-4)  was used to assess adherence/non-adherence to antitubercular therapy in patients. TB patients were considered adherent to medication if they answered negatively to all four question. Patients who had missed at least one prescribed dose of TB drug were described as non-adherence.
Total of 72 patients who were attending district tuberculosis centre for at least 2 mo was analysed. Among all 72 patients, the majority were male, illiterate between 40-50 age, and had family income less than INR 10,000. Level of adherence/non-adherence assessed by MMAS (4-item scale) revealed 58 patients (48 males and 10 females) were adherent [table 3] Non-adherence was seen in 14 patients (12 males and 2 females). Travelling distance from their home to the tubercular health centre when analyzed showed that 12 patients had to travel less than 5km and 24 patients had to travel 5-10 km and 36 patients had to travel more than 10km.
When non-adherent patients were analysed for reasons for non-adherence, it was found that forgetfulness was main reason in 6 patients (42.8%), followed by illiteracy in 3 patients (21.4%), longer distance to the health centre in 2 patients (14.2%) both had distance more than 10 KM. While one patient each (7.1%) had side effects, smoking, and mental retardation.
2 patients had shown non-adherence to tuberculosis because of travel distance more than 10 km.
Table 1: Morisky medication-taking adherence scale (4-item)
|Do you ever forget to take your medicine?||Yes||no|
|Do you ever have problems remembering to take your medication?||Yes||no|
|When you feel better, do you sometime stop taking your medicine?||Yes||no|
|Sometime if you feels worse when you take your medicine. Do you stop taking it?||Yes||no|
Table 2: Demographic profile of study participants
|Marital status||no (%)|
|Level of education||no (%)|
|Travelling distance to hospital|
Table 3: Adherence and nonadherence
|Adherence (as per MMAS scale)||No (%)||Male (%)||Female (%)|
|Nonadherent||14 (19.44)||1 2 (16.66)||2(2.77)|
Table 4: Factors associated with nonadherence to antitubercular treatment No (%)
Adherence to medication is the extent to which a person takes medicine as prescribed by the health care provider. It is a key factor for effectiveness of therapy, while non-adherence to medication can result in failure of therapy and manifest as increased morbidity and mortality . The aim of the present study was to evaluate the important issue of non-adherence in patients of tuberculosis.
The current study was conducted in department of pharmacology of GMC Kathua, in collaboration with District Tuberculosis Centre Kathua, which mostly cater rural population.
A baseline demographic information of 72 patients enrolled in study revealed that most of them were males 60(83%), in between 40-50 y of age (38%), illiterate (50%) and belonged to lower income group. Similar to our observations many of the studies have shown that males constituted the majority of tuberculosis patients. However, one study in contrast to our observations revealed females to be more affected with tuberculosis .
Higher number of males in present study, could be due to more outdoor activities of the males which entails higher chances of contracting disease. Females on the other hand prefer indoor work as the study included mostly rural area where males mostly carry outdoor work and females confine to indoor household work.
Majority of patients (50%) were illiterate and higher number of the tuberculosis patients in illiterate group could be due to lack of knowledge regarding the disease and lower socioeconomic status might have further compounded the situation.
Our results revealed the out of 60 male patients, 48(80%) showed adherence to antituberculosis therapy while remaining 12(20%) were non adherent. Whereas out of 12 females in the trial 10(83%) were adherent while 2 female patients (16.66%)were non adherent. This shows that non adherence was more in male patients. This probably could be due to higher number of male patients than females included in current study and thereby implying more chance of number of non-adherence compared to females. Number of studies have similarly shown that males were more non adherent to antituberculosis treatment [14, 16].
Our results revealed that forgetfulness (42%) regarding taking of medicine was foremost cause of non-adherence fallowed by illiteracy (21.4%) and higher distance from health institute (14%), while smoking, side effects of the drugs, mental retardation contributed 7.1% each towards non adherence.
Higher rate of forgetfulness in the present study has also similarly been documented by other. The higher rate of forgetfulness in present study may be to ignorance on the part of the patients, correlating with their educational status, inadequate knowledge about disease. This may also be contributes due to failure on the part of health providers to impart knowledge and education about tuberculosis, ADRs are known to cause noncompliance in patients. In present study 7.14% of non-adherent patients had history of side effects. Similar studies have also shown non adherence due to side effects of the drugs [13-16].
Another important factor contributed towards non adherence in our present study was the distance from home to the health institution (14%). 2 patients had distance more than 10 km. This shows that distance to the health institution is a critical factor for non-adherence. It is to explain as longer distance do deter patient to reach health providing centre. Similar report to our results have also been recorded by earlier studies .
Our study has clearly shown in no unambiguous terms that non adherence is an important issue in the tuberculosis patients. This scenario is of grave consequences as it leads to resistance to anti tubercular drugs, disease relapse and delay in sputum negativity. The forgetfulness regarding taking of medicine, illiteracy, and distance from health institution were major factors contributing towards the non-adherence in the present study. These result calls for drive to increase literacy level and providing health care within reach of the patients to counter non adherence. The health care provider should also educate the patient regarding the disease as well as non-adherence.
The present study has depicted non-adherence in tuberculosis patients. This was found to be more common in males, illiteriate, lower socioeconomic group, higher distance to the health institution. These result calls for appropriate remedial measures.
We would like to thank our district tuberculosis centre staff for their continued support during this project.
All the authors have contributed equally.
CONFLICT OF INTERESTS
There is no conflict of interest.
WHO. WHO global Tuberculosis Report, WHO Press: Geneva, Switzerland; 2016.
Ch K. Factor affecting compliance to tuberculosis treatment in Andra Kanvango region in Nambia. Journal of compliance to TB treatment; 2010.
Hawn TR, Day TA, Scriba TJ, Hatherill M, Hanekom WA, Evans TG, et al. Tuberculosis vaccines and prevention of infection. Microbiol Mol Biol Rev 2014;78:650–71.
Organization, World Health. Implementing the WHO Stop TB Strategy: a handbook for national TB control programmes; 2008. p. 179.
Harris RE. Epidemiology of chronic disease: global perspectives. Burlington, MA: Jones and Bartlett Learning; 2013. p. 682.
WHO treatment of tuberculosis guidelines. In: 4th edition ed: world health organization; 2010.
World health organisation, global tuberculosis control. Surveillance, Planning, Financing. 170, Geneva; 2004.
Tahao Glu K, Torun T, Sevim T, Atac G, Kir A, Karasulu L, Kapakli N. The treatment of multidrug resistant tuberculosis in turkey. N Engl J Med 2001;345:170-4.
McDonnell M, Turner J, Weaver MT. Anticedents of adherence to antituberculosis therapy. Public Health Nurse 2001;18:392-400.
Menzies R, Rocher I, Vissandjee B. Factors associated with compliance in treatment of tuberculosis. Tuber Lung Dis 1993;74:32-7.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.
Santra G. Assessment of adherence to cardiovascular medicines in rural population: an observational study in patients attending a tertiary care hospital; Indian J Pharmacol 2015;47:600-4.
Geethalakshmi RG, Dsouza MJ Ashok. Adherence to non tuberculosis treatment among patients in urban field practice area of Medical College, Devangere, Karnataka, a qualitative study. Int J Community Med Public Health 2019;6:255-8.
A Aashutosh, N Shubhangi, I Manouj. A study on factors associated with non adherence to ATT among pulmonary tuberculosis patients under RNTCP. Int J Med Sci Clin Intervention 2017;4:2759-63.
G Harshul, P Goeka, S Esha, S Hrvy, D Harmony, P Harsh. Across sectional study to assess the non adherence to anti tuberculosis treatment and determinant factors among patients with pulmonary tuberculosis. GCSMC J Med Sci 2017;VI:22-6.
Hanumaiah V, Ranganath DD, Kakkuppi N. Assessment of adherence to antituberculosis medication for successful implementation of revised national tuberculosis programme at a tertiary care hospital. Shimoga: a cross section observational study. Int J Basic Clin Pharmacol 2019;8:2361-6.