Study of factors related to health and health care delivery system amongst defaulters in DOTS centre in Warangal district of Telangana state

 

Tagaram Ramchandra¹, Niharika Lakkoju^2*

 

¹Assistant Professor, Department of Community Medicine, Shadan Institute of Medical Sciences, Hyderabad, Telangana, INDIA.

²Department of Community Medicine, Kakatiya Medical College, Warangal, Telangana, INDIA.

 

Abstract               Background: Tuberculosis (TB) is a major public health problem in the world and is a social disease with medical aspects. Quality of health and health care delivery system plays an important role in the status of tuberculosis (TB) control, by influencing timely diagnosis, adherence and treatment completion. The present study was carried out to find out the factors related to health care system among TB defaulters. Methods: A cross sectional study was carried among 106 defaulters of TB patients in 3 TB units (TU) out of 7 TB units in Warangal district, attached to District Tuberculosis Centre (DTC) from July 2014 to May 2015 by interview technique utilising a pretested and structured questionnaire to collect the data. Statistical analysis was done by using percentage, proportions and chi-square test whenever necessary. Results: Most of the defaulters had received their initial treatment in PHC’s 41(38.7%) followed by in private hospitals i.e., 36 (34%) and the observed difference between 3 groups was found to be statistically significant. 50.9% of defaulters took treatment for only 1-3 months and the difference among 3 TU’s found to be statistically significant while taking medicines. 62.3% of the DOTS providers were friendly and 26.4% providers were indifferent and very unfriendly towards the study population. 73.6% of families got counselled by health workers and 54.7% of patients were supervised by health worker while taking medicines. Medicines always available only in 88.7% of DOTS centres and 22.6% of DOTS centres were far away from residence of defaulters. Side effects as a reason for default of treatment between 3 TU’s was found not to be statistically significant. Conclusion: The study concluded that default was a major barrier to be dealt in the success of RNTCP program. Majority of defaulted between 1-3 months from anti-TB treatment and 26.4% of families of defaulters didn‘t get counselled by health workers. Only 54.7% of patients were supervised by Health Workers. Most common side effect experienced by study group was vomiting and abdominal pain- GI upset. There was an opinion received from patients that staff in DOTS centres should be well trained to treat complications.

Key Words: Defaulters, DOTS, District tuberculosis centre (DTC), Tuberculosis (TB), Tuberculosis unit (TU).

 

 

 

INTRODUCTION

Tuberculosis (TB) is a major public health problem in the world with a current global picture of 10.4 million incident cases of which 5.9 million cases were among men and 3.5 million cases were women and 1 million were among children during 2015. It cause ill-health among millions of people each year and ranks as the second leading cause of death from an infectious disease worldwide after Human Immunodeficiency Virus. There were estimated 1.4 million TB deaths in 2015, and an additional 0.4 million deaths in TB with HIV cases. TB remained one of the top 10 causes of death worldwide in 2015.¹ The WHO South East Region with an estimated 5.4 million prevalent cases and 4 million in terms of incidence. Out of 22 high burden countries, India accounting for 23 percent and 167 incident cases per 100,000 Population and incidence rate of HIV with TB cases is 8.3 per 100,000 Population during 2014.²

Tuberculosis is a social disease with medical aspects. The available therapeutic regimens have inherent disadvantage of long treatment duration, resulting in patient’s non-compliance along with the risk of drug resistance. Hence new modalities of treatment that are potent against active resistant strain are needed to combat these diseases. Quality of health and health care delivery system plays an important role in the status of tuberculosis control, by influencing timely diagnosis, adherence and treatment completion. Therefore, the present study was carried out to find out the factors related to health care system among TB defaulters.

 

MATERIALS AND METHODS

A cross sectional study was carried amongst 106 defaulters of TB patients in 3 TB units (TU) out of 7 TB units in Warangal district. Area covered by 3 TB units consists of Warangal TU (Urban), Thorrur TU (Rural), Govindaraopet TU (Tribal), attached to district tuberculosis centre (DTC) from July 2014 to May 2015. Lottery method was adopted for selecting three TB units (40%) out of seven in Warangal district i.e. one from each area. For this study, only defaulters of DOTS who were enrolled in TB registers of concerned TB units were taken as study sample. The addresses of defaulters were obtained from TB registers of concerned TB units. In 2014, total TB cases were registered in selected TU’s were 1266 and 126 defaulters among them. The patients were contacted at their homes by giving brief idea about the objectives and informed about the study. Data obtained from 106 defaulters on a voluntary basis. Those who were died, absconded and migrated were excluded from the study. Method adopted to obtain data was the “Interview technique.”Warangal district headquarters is situated at distance of 146 kms from Hyderabad city (Telangana) consists of 3 cities Warangal, Hanamkonda and Kazipet. District Tuberculosis Centre (DTC) is 9 kms away from Kazipet railway junction. The DTC has 7 TB units (TU) and each is attached with 5 to 6 microscopy centres. Urban TU located at DTC, Warangal. Rural and Tribal TU areas located at a distance of 100 km from DTC and DTC covers total of 1097 villages.

Statistical Analysis: Data was entered into Microsoft Excel and analyzed using the Statistical Package of Social Sciences (SPSS) version 22.0. Statistical significance was set at P≤0.05.

RESULTS

It was seen from Table 1 that among the study population 62.3% of the DOTS providers were friendly and 26.4% providers were indifferent and very unfriendly towards the study population, the family has an important role in health and disease and especially from TB patients who require continuous support and care both from the health system and their family. 73.6% of families were counselled whereas 26.4% didn’t get counselled by health workers and 54.7% of patients were supervised by health worker while taking medicines. Medicines were adequate in 88.7% of dots centres, while 8.5% of DOTS centres drugs supply was inadequate and 22.6% of dots centres were far away from residence of defaulters.

 

Table 1: Health Care System Related Factors Related to Default in Government Setup

Table 2: Supervision of Health Workers while Taking Medicine

Chi-square= 7.74 df= 2 p <0.02

According to Table 2, majority 54.7% of the study population has taken medicines under supervision of health workers in which 23.5% of the urban study population were supervised by health workers compared with rural (17.9 %) and tribal areas (13.3%), the difference was found to be statistically significant.

 

Table 3: Too Many Tablets as a Reason to Default from Treatment

     Chi-square= 7.613 df=2 P <0.022

It was observed from Table 3 that 35.8% of the study population had consumed too many tablets in which majority 23.5% were of the urban study population and the difference was found to be statistically significant.

Table 4: Distribution of Defaulters According to Their Previous Treatment Sector among Study Population of 3 TB Units

  Chi-square= 13.509, df= 6, p<0.036

According to Table 4, among the study population majority 40 (37.7%) had their initial treatment in PHC’s followed by in private hospitals 37 (34.9%). Majority of the urban study population took their initial treatment in higher and private sectors than rural and tribal groups. The observed difference between 3 groups was found to be statistically significant.

 

Table 5: Distribution of Study Population According to Time When Default Occurred

As shown in Table 5, default occurred between 1-3 months in 50.9% of the study population and 49.1% were defaulters after 3 months of medication.

Table 6: Distribution of Side Effects among Study Population

According to Table 6, of all the defaulters’ majority 49.1% experienced vomiting and abdominal pain (GI upset) as side effect, followed by giddiness (43.4%) and 21.7% had joint pains, 17% loss of appetite, 16% indigestion, 13.2% discolouration of urine, 10.4% rashes, and 9.4% burning sensation in hands and feet and 3.8% of defaulters experienced jaundice as side effect due to anti-TB drugs. Many defaulters had more than one side effect.

Table 7: Side Effectsas a Reason to Stop the Treatment among Study Population of 3 TB Units

    Chi-square = 0.432, df=2, p <0.806

As depicted in table 7, among the study population side effects as a reason for default of treatment was seen less in tribal TB unitsthan in rural and urban area. The observed difference between 3 groups was found not to be statistically significant.

 

Table 8: Fear of Discrimination among the Study Population

According to Table 8, among the study population the fear of discrimination was observed in 26.4%.

 

Table 9: Distribution of co-morbidities among Defaulters

As per Table 9, majority (82%) of defaulters had no comorbidities. Among the defaulters with comorbidities Diabetes (10.4%) was more common followed by HIV (5.7%).

Table 10: Opinions of Patients to complete their Treatment in 3 TB units

According to Table 10, majority (26.4%) of patient’s opinion that staffs were well trained in treating complications.19.9% of population had an opinion that other medicines are to be taken to improve strength. Remaining population had an equitable thought of family support need, economic support, and have to cut short tablets.

 

DISCUSSION

In our study, most of the defaulters had received their initial treatment in PHC’s 40 (37.7%) followed by private hospitals 37 (34.9%). The majority of urban study population took their initial treatment in higher and private sectors than rural and tribal groups. Similar findings were found in a cross-sectional study done in Ethiopia by Wondimu T et al² which stated that 35.6% of patients reported first to pharmacies, private clinics or private hospitals upon recognition of symptoms and 43% of patients reported first to either health centres or government hospitals. A study from Mumbai found that when 106 private practitioners were asked to write a prescription for a patient with pulmonary TB, 6 in an urban slum, 3 different drug regimens were prescribed, and only 6 of these prescriptions were found to be appropriate.³ The private sector in India is highly unorganized, Practitioners of various alternative forms of medicine often prescribe anti–TB drugs without being qualified to do so.⁴ More han half 54.7% of the study population has taken medicines under supervision of health workers of which 23.5% of the urban study population were supervised by health workers compared with rural (17.9%) and tribal areas (13.3%). Volmink J et al⁵, published a review on directly observed therapy and treatment adherence that these DOTS programmes were using a variety of interventions in addition to DOT, such as incentives (free meal and transport coupons), defaulter actions (including court–mandated involuntary admission or incarceration), and patient-centered designs (giving patients a range of supervision options, and focusing on their convenience). In our study, 35.8% of patients defaulted due to intake of too many tablets as many of them had other co-morbidities (18%). This finding was similar with study done by Gebremariam et al⁶ that patients attributed pill burden to be one of the major challenges of concomitant treatment, they used expressions such as becoming a drug bag and becoming a pharmacy. In addition to anti-TB drugs and antiretroviral drugs, patients co-infected with TB and HIV were also taking co-trimoxazole prophylaxis and some in addition had to take drugs for other diseases. The study by Padmapriyadarsini C et al⁷ reported that where the treatment of HIV co-infected patients required anti-TB and antiretroviral drugs to be administered along side, there were challenges of pill burden, patient compliance, drug interactions, overlapping toxic effects and immune reconstitution inflammatory syndrome. In this study, 39.6% patients took treatment for only 3 months and 34.0% underwent treatment for only 2 months. Similarly study by Subbaraman R et al⁸ found that 20% defaulted, treatment interruption occurred during continuation phase in 91% of defaulters. These results are similar to present study as treatment interruption occurred during continuation phase in 74%. Another study by Singh G et al⁹ also found that many patients who did not receive directly observed treatment, stopped taking drugs from the 4th month. In the present study, 96 (90.6%) participants experienced side effects, of which vomiting and abdominal pain (GI upset) was most common (49.1%) followed by giddiness (43.4%). Most of them experienced more than one side effects. This was consistent with a study conducted in Ethiopia by Tekle B et al¹⁰ found side effects to be statistically significant. According to the WHO, most TB patients complete treatment without experiencing significant side effects on taking the TB medicines. The few patients who report or develop side effects commonly present with skin rashes, visual and auditory disturbances, jaundice, burning sensations in the limbs and painful limbs. The fear of side effects has lead to poor compliance of patients over treatment. Therefore, attention should be paid to diagnosis and prompt treatment of side effects, as well as educating patients about the possible side effect.¹¹ Stigma and discrimination will cover disclosure issues. Majority 73.6% of all defaulters had disclosed their TB status to a family member or friend. Only 26.4% respondents didn’t disclose their TB status to anyone, giving reasons such as no one to trust and fear of being isolated by family and friends. Although disclosure status did not show any significant difference between the 3 studies groups (urban, rural, and tribal). Similarly study by Kaona et al¹² reported stigma and discrimination of TB patients as affecting treatment compliance. A study by Eastwood SV et al¹³ also showed that the perceived presence of stigma and discrimination in a community may act as barriers to patients disclosing their disease to family or community members, who may provide the much needed psychosocial support to the patient. Co-morbidities are illnesses occurring together, usually with one of the medical conditions or illness leading to the occurrence of the other.¹⁴ In the present study, there were several responses from the patients when they were asked their opinion on what could be done to help TB patients to complete their treatments. 38.7% of defaulters requested food to be made available for patients taking treatments, followed by 17.9% who asked for provision of medicines in one place for those with other medical conditions, 16% wanted more trained staff at TB clinic, 15.1% of patients to admit in hospital until they complete treatment and 12.3% requested to provide incentives to family to complete their treatment. Similarly by Maher D et al¹⁵ and Jaiswal A et al¹⁶ studies on patients defaulting from treatment in India has shown that inconvenience of clinic timing resulting in loss of wages, costs of travel to clinic, lack of provision for continuity of treatment in case of a family emergency which precluded a visit to the clinic, lack of respectful communication between staff and the patient, and inadequate information and poor management of adverse events and toxicity continue to result in patients defaulting from treatment.

 

LIMITATIONS

The study was only carried out in 3 TB units out of 7 in one district due to financial and time constraints, therefore it will not be easy to generalize to other areas.

CONCLUSION

Thus from the above findings it can be concluded that default is a major barrier to be dealt in the success of RNTCP program. Majority 50.9% defaulted between 1-3 months from anti-TB treatment. Low levels of knowledge about disease and treatment in tribal TU area as compared to rural and urban TU areas. Regarding health care system, among the DOTS providers, 26.4% of providers were indifferent behaviour and very unfriendly towards the study population 26.4% of families of defaulters didn‘t get counselled by health workers. Only 54.7% of patients were supervised by Health Workers and the difference among 3 TU’s found to be statistically significant while taking medicines. In 8.5% of DOTS centres drugs supply was irregular. 22.6% of DOTS centres were far away from residence of defaulters. Lack of family support and too many tablets were associated with defaulting and the difference was found to be statistically significant. Most common side effect experienced by study group was vomiting and abdominal pain- GI upset (49.1%) giddiness, joint pains, jaundice etc .There was an opinion received from patients that staff in DOTS centres should be well trained to treat complications.

 

RECOMMENDATIONS

Establish more DOTS centres and ensure DOTS providers working properly or not. Staff recruitment in areas where ever centre is far away. Try to provide a one-stop-service at health facilities, so that patients with multiple medical conditions can be attended and provided different health services. Health education should be intensified within the communities and in private hospitals, particularly at the beginning of treatment and with reinforcement at each visit using the local language.

 

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