Patient adherence to Directly Observed Therapy (DOT) for Tuberculosis in a rural community in Gujarat, India. Público

Abstract

Abstract

Background: India has one of the highest incidences of tuberculosis worldwide. The greatest impact of the disease is on the rural community, where poor adherence to treatment is a major constraint to prevention and control. Research assessing non-adherence to directly observed therapy (DOT) in India has often used a quantitative approach and has focused on urban areas; however, DOT-adherence among the most vulnerable (the rural poor) is not well understood.

Objective: This study examines patient adherence to DOT by assessing factors associated with DOT outcomes in a rural community, validating its treatment outcome reliability and understanding the details on socio-cultural influence, the different pathways of behavior and possible recommendation for strengthening adherence to the programme.

Methods: A mixed method study was conducted to measure factors associated with DOT outcomes and to explore the experience of DOT recipients and providers. Logistic regression analysis was employed for quantitative assessment on the 592 Tuberculosis patients registered for DOT from July 2007 through December 2009. For qualitative portion, in-depth interviews were conducted with 21 participants including both recipients and providers of DOT.

Results: In general, the treatment outcomes indicated relatively high cure rate under DOT. However, the reliability of the data are still questionable, and re-treatment due to relapse case has shown significant association with both default and failure patients. The key findings of the study reveal that barriers to DOT adherence stem from a multiple dimensions of socio-cultural influences, leading to a clash between cultural and public systems as well as a gap between patient and provider's perspectives. Both quantitative and qualitative studies indicated the importance of the tribal status in adhering to DOT.

Discussion: Despite high cure rate demonstrated by the tuberculosis registers, gender-specific stigma differentials, class/status inhibitions and traditional custom underline key dimensions of socio-cultural barriers to DOTS adherence. The findings of the study can be used to build on the existing interventions to further strengthen the efficacy of DOT in low-socioeconomic rural populations, contributing in an effort to positively modify TB epidemiology in future.

Table of Contents

Table of Contents
I. List of Tables and Figures...v
II. List of Appendices...vii
III. Chapter 1: Introduction & Background...1

1.1. Global Epidemiology of Tuberculosis...1
1.2. Intervention against Tuberculosis...2
1.3. Tuberculosis in India...3
1.4. Background Information of DOTS programme...8

1.4.1. DOTS Strategy...8
1.4.2. Revised National TB Control Programme (RNTCP), India...8
1.4.3. Definitions under the RNTCP...10

IV. Chapter 2: Review of Literature...12
V. Chapter 3:...22

3.1. Methodology...22

3.1.1. Introduction...22
3.1.2. Study setting and design...22
3.1.3. Quantitative...23

3.1.3.1. Study setting and population...23
3.1.3.2. Factors and factor definitions...23
3.1.3.3. Data collection...24
3.1.3.4. Statistical Analysis...25

3.1.4. Qualitative...26

3.1.4.1. Study population...26
3.1.4.2. Participant recruitment...27
3.1.4.3. Data Collection...27
3.1.4.4. Data analysis...28

3.1.5. Ethical consent...29

3.2. Results...30

3.2.1. Quantitative Results...30

3.2.1.1. Patient Characteristics...30
3.2.1.2. Factors for treatment default...31
3.2.1.3. Factors for not giving final sputum check at treatment completion (i.e.‘completed')...32
3.2.1.4. Factors for cured patients...33
3.2.1.5. Factors for failure...34
3.2.1.6. Factors for death...35
3.2.1.7. Factors for non-defaulting vs. default...36
3.2.1.8. Factors for being cured vs. not cured upon treatment completion...36
3.5.1.9. Validation of treatment outcomes identified by district TB Unit...37

3.2.2. Qualitative Results...38

3.2.2.1. Characteristics of Tuberculosis Patients and DOT Providers...38
3.2.2.2. Socio-cultural Influences on patient adherence behavior...40

3.2.2.2.1. Stigma...40

3.2.2.2.2. Class/Status Inhibitions...44
3.2.2.2.3. Traditional Customs...52
3.2.2.3. Economic Issues...53
3.2.2.4. Provider's Perspectives on DOT system and Patient-Provider Relationships...56
3.2.2.4.1. DOT System...56
3.2.2.4.2. Attitude towards Patients...57

VI. Chapter 4:...61

4.1. Discussion...61
4.2. Conclusion...68

4.2.1. Limitation and Interesting note...69

4.3. Public Health Implications & Recommendations...70

VII. References...76
VIII. Tables and Figures...80

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palabra Clave	Tribes Rural community Tuberculosis Patient adherence TB treatment Socio-cultural influence directly observed therapy (DOT) SEWA-RURAL Qualitative study Gujarat, India DOTS strategy Mixed method study
Committee Chair / Thesis Advisor	Hennink, Monique, Emory University
Committee Members	Brachman, Philip, Emory University
Partnering Agencies	Community-based non-profit organization (e.g., AID Atlanta) Non-US governmental agency (e.g., Minister of Health in Haiti) Hospital or other health care provider

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