Adherence to antituberculosis therapy in Cape Town

Dick, Judy Margaret

Adherence to antituberculosis therapy in Cape Town

Thesis / Dissertation

1995

Publisher

University of Cape Town

Department

Department of Public Health and Family Medicine

Faculty

Faculty of Health Sciences

Abstract

Effective antituberculosis chemotherapy was developed during the 1950s, yet 4 decades later the cure rates for tuberculosis (TB) worldwide remain unacceptably low. A major reason for the failure to eliminate TB is that many patients with active disease fail to take sufficient antituberculosis medication to render a cure. The failure of sputum smear-positive patients to adhere to treatment leads to the further transmission of the disease, and is the major reason for the escalating development of drug-resistant strains of TB. The Western Cape Region of South Africa has the highest reported incidence of TB in the world, the highest prevalence of the disease being in the coloured population. In this thesis, a retrospective longitudinal study of 3538 adult pulmonary TB patients notified in Cape Town during 1991, found that only 56,4% were found to have completed 75% or more of the prescribed medication. Thirty-one per cent of this cohort were cases being treated for recurrent disease, the majority of whom had exhibited poor adherence in their previous treatment episode. Due to inefficient and inadequate monitoring of patients' adherence patterns, local health authorities remain unaware of the extent of the problem of nonadherence. The TB control programme procedures at clinic level were reviewed to reveal that clinic staff managed the TB clinics in a rigid, task-orientated manner. During crowded TB clinic sessions each patient was 'processed' by a series of clinic staff, with each specific activity preceded by periods of waiting. Despite the implementation of supervised daily treatment, there was no evidence of any proactive case-holding protocol to assist the newly notified TB patient cope emotionally with the adjustment to the diagnosis of TB, or to help the patient identify potential barriers which might prevent them from maintaining regular treatment for the duration of 6 months. Patient adherence was viewed by many clinic staff to be the sole responsibility of the TB patient; non-adherent treatment behaviour was viewed as 'irresponsible' and 'deviant'. The adherence literature reviewed in this thesis challenged the stance that adherence is the sole responsibility of the TB patient, and instead introduced the concept of case-holding as being a co-operative effort between the health care provider and patient. Adherence to treatment should be perceived as task-specific behaviour, and the role of the health care provider as assisting the patient achieve this task. The successful completion of regular daily observed therapy is frequently challenged by competing demands on the patient's time, contradictory norms or expectations of the patients' families or cultural groups, and difficulties in communication between the patient and health care providers. The principles advanced in Bandura's theories of social learning and self-efficacy were incorporated into a series of participatory research projects which investigated the quality of the interaction between the clinic nurse and the TB patient, and the information needs of newly diagnosed TB patients. This information was incorporated into a health education strategy which was tested in a demonstration model in Mitchell's Plain. The risk of nonadherence was significantly reduced at the experimental clinic (Eastridge) compared to the control clinic (Lentegeur). The very large caseload in many of the Cape Town clinics makes the patient-centred approach difficult. The second section of the research was thus directed towards providing a critique for the development and assessment of the impact of a pilot outreach programme designed to supplement the conventional TB control programme in the area. It was found that although volunteer community health workers have the potential to extend personalised health care to under-served communities, their impact on enhancing adherence to treatment in the area of Elsies River was limited. The degree of supervision and support required for project staff was underestimated during the developmental stages of the project. During the early stages of the thesis the assumption was made that adherence-enhancing strategies could be developed to supplement existing patterns of health care delivery. However, all adherence-enhancing strategies are client-orientated in nature. During the research process it became evident that the TB control programme had been divided into a series of tasks or activities to make the flow of activities as convenient as possible for the clinic staff. This task-orientation failed to meet the essential needs of TB patients, thereby failing to maintain their motivation to adhere to antituberculosis therapy. The World Health Organisation (WHO) argues that the 'tools' to control TB are available but poor cure rates are due to the failure to adapt the innovative technologies to the local situation. Most problems in the TB control programme are health service delivery-related, not technological. If the local health authorities are serious about their intent to quell the escalating TB epidemic, they will need to identify case-holding as the priority in the TB control programme. The programme will need to be goal-directed, and will have to design explicit case-holding procedures to achieve these goals. It is suggested that case-holding processes be based on the principles of Bandura's social learning theory, which are: to explain the treatment behaviour expectations; to identify and plan for potential barriers to adherence; to provide role models for patients - these would be patients who have been successful in completing treatment; to provide systematic feedback to the patient on their progress in treatment; and to provide a system of support to patients in treatment. This will require the redesign of the delivery of primary health care from the narrow bio-medical approach which focuses on the disease, to a more holistic patient-centred approach which concentrates on the patient's illness experience.

Keywords

tuberculosis

chemotherapy

Reference:

Collections

PhD / Doctoral

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