Non-Adherence to Anti-Tuberculosis Treatment among Newly Diagnosis Tuberculosis Patients Treated under DOTS in District Raipur, Chhattisgarh

Introduction

TB was the world's second biggest cause of mortality from a single infectious agent, behind coronavirus disease (COVID-19), and it killed nearly twice as many. People with HIV/AIDS. According to the World Health Organization (WHO) Global Tuberculosis Report 2023, there were an estimated 10 million new tuberculosis cases worldwide, of which 5.8 million (55%) were males, 3.5 million (33%) were females and 1.3 million (12%) were children. 6.3% of People living with HIV of all new tuberculosis cases worldwide in 2022. Eight countries accounted for more than two-thirds of the new cases: India, Indonesia, China, the Philippines, Pakistan, Nigeria Bangladesh, and the Democratic Republic of the Congo [1]. Though the Government of India (GoI) has taken several steps towards TB elimination, the disease continues to be a major public health problem in the country [2]. World Health Organization (WHO) has recommended a Directly Observed Treatment Short Course (DOTS) strategy for global tuberculosis control which is accepted worldwide. DOT is the best method to improve the cure rate of tuberculosis. This strategy includes the delivery of a standard short course of drugs, lasting 6 months for new patients and 8 months for previously treated patients who are diagnosed with TB. The delivery of therapy includes the direct observation of either by a health worker or by someone nominated by the health worker for this purpose [3].

The Revised National Tuberculosis Control Program (RNTCP) based on DOTS was launched in 4 districts of Chhattisgarh on August 15, 2002, and achieved statewide coverage in the year 2004. A total of 27 District Tuberculosis Centers (DTCs), 152 Treatment Units (TUs), and 551 Designated Microscopic Centers (DMCs) are providing diagnostic and treatment services in the state. Tuberculosis suspects examined per lakh population has increased from 452/lakh in the year 2013 to 652/lakh in the year 2015 [4]. Decentralizing the diagnostic services for Drug-Resistant Tuberculosis, the Cartridge Nucleic Acid Amplification Test (CBNAAT) is installed in almost all districts of the state.

Chhattisgarh is currently facing several challenges with communicable and non-communicable diseases. Tuberculosis is one of the communicable diseases which is most prevalent in Chhattisgarh. The non-adherence to anti-tuberculosis treatment among patients with tuberculosis is the common reason for an increasing number of Multi-Drug Resistant (MDR) and Extensively Drug Resistant (EDR) tuberculosis, and decreasing cure rate in the state. Patients who interrupted the anti-tuberculosis treatment (ATT) for more than 30 consecutive days were considered non-adherent. Hence this study assessed the knowledge about tuberculosis among non-adherent tuberculosis patients and identified the reasons for non-adherence to anti-tuberculosis treatment among newly diagnosed tuberculosis patients registered under the Revised National Tuberculosis Program (RNTCP) in Raipur district, Chhattisgarh.

Materials and Methods

Results

Discussion

In the present study, we found most of the non-adherent patients were male in the age group of 31-50 years and illiterate. Similar findings have been documented by Kulkarni P et al also found that the majority of non-adherent patients were males between 15-49 years [5]. The present study reveals that the maximum number of non-adherent patients 80.9% were married and Hindu (89.4%). Similar findings were observed by Suparna Bagchi et al, in their study where 65% were married and 78% were Hindu. Chhaya Mittal et al also reported that the maximum number of non-adherent patients were Hindu (15.9%) [6][7].

We found a significant number of non-adherent patients 61.3% interrupted ATT during the intensive phase because some of the patients felt better after a few weeks of treatment and some of them were not aware of the total duration of treatment, which is close to the findings of another study done by Kulkarni P et al reported that 51.3% of non-adherent patients were interrupted ATT during intensive phase due to similar reasons which we found [5].

The majority of the patients (34%) stopped their treatment during the 3rd month, followed by 32% during the 2nd month because one of the most common reasons was they felt better and relieved from symptoms after a few months of treatment and considered as they cured. The second most common reason was they did not know about the duration of treatment. A similar pattern of treatment interruption has been also reported by other studies. Sweta Gupta et al found that 72% of patients stopped taking medicine during the 3rd month and a maximum of 30.28% interruptions were found between the 2^nd and 3^rd months [8].

The study shows that the majority of the TB patients, 80.9% had heard about tuberculosis before diagnosing it and the major sources of information were health workers (42.6%) followed by mass media (27.7%). A study conducted by Das R et al revealed a similar fact where 92.3% heard about tuberculosis before diagnosis and got information from the community (35.9%) followed by health workers (32.3%) [9]. another study conducted by Pramanik D et al also found that most of the patients, 52% had heard about tuberculosis and the major source of information was health workers (26%) [10].

We found that about three-quarters (75.5%) of the respondents knew that tuberculosis was a communicable or infectious disease. Similar findings were also reported in the study conducted by Mukhtar A. et al where 78.7% of patients were aware TB that is a communicable disease [11].

The study shows that nearly half of the studied patients (49%) knew the modes of transmission of the disease. Similar findings have been reported by Mahendra Singh Rathore et al in their study conducted in Udaipur (Rajasthan), they found that about 66.95% of patients knew about the transmission of the disease [12] Knowledge regarding the prevention of transmission of disease, the maximum 36.2% of TB patients replied that cover their mouth and noses while coughing. Similar findings were also observed by Das R et al reported that the majority of the TB patients (53.60%) replied as avoiding uncovered coughing [9].

The current study shows that the majority of TB patients (63.8%) correctly knew about the total duration of anti-tuberculosis treatment and some of the patients were still unaware of the total duration of course. Pramanik D and Ghosh JR reported a similar fact that most of the patients knew the duration of the course [10].

While assessing the main reasons for the Interruption of ATT, we observed that the most common reason for the interruption of ATT among tuberculosis patients was the side effects of drugs, reported by 27.7% of patients. Similar facts were also found in Chhaya Mittal et al demonstrated that side of drugs (43.2%) was the main reason for interrupting ATT among TB patients [13] (Table- 4)(Graph- 1).

In our study alcohol consumption was the second most common reason for interruption of ATT, as reported by 23% of patients. W. M. Jakubowiak et al reported that the second most common reason for stopping ATT was alcohol use (29.8%) [14].

The third most common reason for interruption of ATT was to feel better or relieved from symptoms of the disease. They considered themselves cured, as reported by 21.3% of patients. Sweta Gupta et al found that feeling early improvement from symptoms of the disease was the first reason for treatment interruption, reported by 30% of TB patients [8].

The next most common reason for treatment interruption was migration (8.5%) either from the native place or searching for new jobs. Kulkarni P et al reported that going to a native place (30.8%) was the first reason for stopping ATT [5].

We found that up to 6.4% of TB patients stopped taking ATT due to the reason of they did not consider themselves sick. Similar findings were also found by W. M. Jakubowiak et al in their study as the third most common reason for interrupting ATT. Reported by 25.3% of patients [14].

Another reason for interrupting the anti-tubercular drug TB patients is because they did not believe in the government hospital and wanted to complete their medication from other private hospitals reported by 6.4% of TB patients. K. Jaggarajamma et al also revealed the same facts [15]. 4.3% of TB patients stopped their medication in between the course because of co-morbidity or having another disease along with TB.

Limitations

The present study's main limitations were its small sample size and a lack of time. Most of the time, patients were not at home because they had to go to work, which made it difficult to trace the patients for interviews.

Recommendations:

Patients, their relatives, and the community are educated about tuberculosis utilizing IEC materials such as flex, posters, slogans, pamphlets, and so on.

Improving awareness about the disease and motivating the patients during treatment may improve adherence to ATT. Adherence to the ATT is a quite challenge when the patients are alcoholics hence special attention and motivation should be given to these patients for adherence to the treatment.

Regular counseling and monitoring should be given to the patients who are having side effects of drugs and co-infection with other diseases because they are more likely to stop the ATT in between the course.

Conclusion

The present study reveals that most of the patients heard about TB but there is a significant knowledge gap among the TB patients about the disease transmission, preventive measures of the disease, and the duration of the treatment. Misconceptions are also present among. Smear-negative tuberculosis patients did not consider themselves sick because most of them did not know about X-ray findings. Some of the tuberculosis patients had stopped their therapy during the first phase or after completing the first phase of treatment because most of them were not aware of the total duration of treatment. The present study also reveals that the most common regions for stopping ATT were side effects of anti-tubercular drugs, alcohol consumption, feeling better after a few months of treatment, migration of the patients to either the native place or searching for new work, having co-morbidity with other disease and accident. Some of the patients did not believe in the government facilities and wanted to complete their treatment at other private hospitals.

Ethical consideration

Ethical clearance for the study was obtained from the Institutional Ethical Committee (IEC) University of Hyderabad, Telangana.

Acknowledgment

Special thanks to Dr. M. Surya Durga Prasad, Assistant Professor, University of Hyderabad, for his support to research. Also, thanks to Dr. Satyanarayan Pandey (District Tuberculosis Officer), District Tuberculosis Center, Raipur, Chhattisgarh, for allowing data collecting. Special thanks to all who assisted in visiting interviewees' homes, and all study participants deserve recognition for their cooperation.

References

1. World Health Organization. Global Tuberculosis Report World Health Organization; 2023. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports.
2. Thomas BE, Thiruvengadam K, Vedhachalam C, Rao VG, Vijayachari P, Rajiv Y, V R, Bansal AK, Indira Krishna AK, Joseph A, Hussain T. Prevalence of pulmonary tuberculosis among the tribal populations in India. PLoS One. 2021 Jun 4;16(6): e0251519. [doi:10.1371/journal.pone.0251519]
3. World Health Organization. An expanded DOTS framework for effective tuberculosis control. Int J Tuberc Lung Dis.. 2002;6:378-88. https://pubmed.ncbi.nlm.nih.gov/12019913/
4. Directorate of Health & Family Welfare Government of Chhattisgarh. 2017 (2017). [Google Scholar]
5. Kulkarni PY, Akarte SV, Mankeshwar RM, Bhawalkar JS, Banerjee A, Kulkarni AD. Non. Adherence of new pulmonary tuberculosis patients to anti. Tuberculosis treatment. Annals of medical and health sciences research. 2013 Apr 23;3(1):67-74. https://pubmed.ncbi.nlm.nih.gov/23634333/
6. Bagchi S, Ambe G, Sathiakumar N. Determinants of poor adherence to anti-tuberculosis treatment in Mumbai, India. International journal of preventive medicine. 2010;1(4):223. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075517/
7. Mittal C, Gupta SC. Noncompliance to DOTS: How it can be decreased. Indian Journal of Community Medicine. 2011 Jan 1;36(1):27-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104704/
8. Gupta S, Behera D. Reasons for interruption of anti-tubercular treatment as reported by patients with tuberculosis admitted in a tertiary care institute. The Indian journal of tuberculosis. 2011 Jan 1;58(1):11-7. https://pubmed.ncbi.nlm.nih.gov/21434551/
9. Das R, Baidya S. A study on knowledge of pulmonary tuberculosis and DOTS among pulmonary tuberculosis patients in west Tripura district, India. SAARC Journal of Tuberculosis, Lung Diseases and HIV/AIDS. 2015;12(1):1-7. https://www.nepjol.info/index.php/SAARCTB/article/view/15935
10. Pramanik D, Ghosh JR. Knowledge and awareness of tuberculosis among pulmonary tuberculosis patients in a rural area of West Bengal. SAARC Journal of Tuberculosis, Lung Diseases and HIV/AIDS. 2015;12(2):13-9. https://www.nepjol.info/index.php/SAARCTB/article/view/15950
11. Sollimana MA, Hassalia MA, Al-Haddada M, Hadida MM, Saleema F, Aljadheyc H. Assessment of knowledge towards tuberculosis among general population in North East Libya. Journal of Applied Pharmaceutical Science. 2012 Apr 30(Issue):24-30. https://japsonline.com/abstract.php?article_id=422&sts=2
12. Chuncha SB. A Study to Assess the Knowledge and Attitude Regarding Tuberculosis and Its Prevention Among Adults in Selected Rural Area of Byahatti Phc with a View to Develop an Information Booklet (Master's thesis, Rajiv Gandhi University of Health Sciences (India)). https://www.researchgate.net/publication/276837647
13. Mittal C, Gupta SC. Noncompliance to DOTS: How it can be decreased. Indian Journal of Community Medicine. 2011 Jan 1;36(1):27-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104704/
14. Jakubowiak WM, Bogorodskaya EM, Borisov SE, Danilova ID, Lomakina OB, Kourbatova EV. Social support and incentives programme for patients with tuberculosis: experience from the Russian Federation. The International Journal of Tuberculosis and Lung Disease. 2007 Nov 1;11(11):1210-5. https://pubmed.ncbi.nlm.nih.gov/17958983/
15. Jaggarajamma K, Sudha G, Chandrasekaran V, Nirupa C, Thomas A, Santha T, Muniyandi M, Narayanan PR. Reasons for non-compliance among patients treated under Revised National Tuberculosis Control Programme (RNTCP), Tiruvallur district, south India. Indian Journal of tuberculosis. 2007;54(3):130-5. [doi:10.5005/jp/books/10992_63]