|Year : 2013 | Volume
| Issue : 2 | Page : 44-49
Initiation and adherence to TB treatment in a Pakistani community influenced more by perceptions than by knowledge of tuberculosis
School of Public Health, Dow University of Health Sciences, Karachi, Pakistan
|Date of Web Publication||18-Dec-2013|
School of Public Health, Dow University of Health Sciences, Karachi
Source of Support: None, Conflict of Interest: None
Background: The tuberculosis (TB) literature is written almost entirely from a biomedical perspective, while recent studies show that it is imperative to understand lay perception to determine why people seek treatment and may stop taking treatment. Aims: To investigate knowledge about TB, perceptions of (access to) TB treatment, and adherence to treatment among a Pakistani population. Setting and Design: Descriptive cross-sectional study. Materials and Methods: A total of 175 participants were selected nonrandomly, 100 were TB patient and 75 were non-TB patient in proportion to the total number of participants in each ward of hospital. Statistical Analysis: Analysis of attitudes and perceptions toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types done by frequency counts and percentages. Regression analysis and logistic regression analysis were performed to test whether differences in age, gender, and education level led to different knowledge scores and different attitudes and preferences toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 16.0. Result: TB knowledge can be considered fairly well among this community. Respondents' perceptions suggest that stigma may influence TB patients' decision in health seeking behavior and adherence to TB treatment. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say. Conclusion: Most of the subjects were unaware of TB that seems to be due to their illiteracy and those who knew had got the knowledge from media, but the majority of the patients who were on directly observed treatment, short-course (DOTS) were found to be satisfied.
Keywords: Adherence, attitude, awareness, knowledge, perception, treatment, tuberculosis
|How to cite this article:|
Zafar M. Initiation and adherence to TB treatment in a Pakistani community influenced more by perceptions than by knowledge of tuberculosis. J Assoc Chest Physicians 2013;1:44-9
|How to cite this URL:|
Zafar M. Initiation and adherence to TB treatment in a Pakistani community influenced more by perceptions than by knowledge of tuberculosis. J Assoc Chest Physicians [serial online] 2013 [cited 2019 Jun 19];1:44-9. Available from: http://www.jacpjournal.org/text.asp?2013/1/2/44/123210
| Introduction|| |
Tuberculosis (TB) is a common infectious disease caused by Mycobacterium tuberculosis.  It most commonly attacks the lungs (as pulmonary TB), but can also affect the central nervous system, the lymphatic system, the circulatory system, the genitourinary systems, the bones, joints, and even the skin.  Over one-third of the world's population now carries TB bacterium, and new infection occurs at the rate of one per second.  TB was declared as global emergency in 1993 by World Health Organization (WHO).  TB eradication has become a priority concern among national, international, and local health authorities. The total global burden is 85%, countries identified as highly endemic countries by WHO.  India, Indonesia, Bangladesh, Thailand, Myanmar, Pakistan, and Afghanistan are in alarming situation, where 50% of global bulk TB cases occur.  TB causes 1.8 million deaths yearly, among them 98% of deaths occur in developing countries.  Studies showed that rates of TB are significantly high in poor populations. ,
TB is a serious and increasing problem in the developing countries like Pakistan, to be a major cause of morbidity and mortality in our country. Factors responsible for TB in Pakistan are late diagnosis, inadequate follow-up. This in turn leads to treatment failure, relapse, and emergence of multidrug resistance (MDR) TB.  As per WHO estimates, about 410,000 new cases of TB develop in Pakistan every year with prevalence of 373 cases per 100,000 population and incidence of 231 per 100,000 populations and the majority of the cases are in productive age group. Although high case detection rates have been achieved in the country by National Tuberculosis Control Programme (NTCP); the delay in diagnosis and unsupervised, inappropriate, and inadequate medicine regimens are some of the reasons for not reaching the target cure rates and emergence of medicine resistant forms of TB. Currently, Pakistan has an annual death rate of 38 per 100,000 people attributed to TB.  Pakistan adopted directly observed treatment, short-course (DOTS) strategy in 1995.  Public awareness programs for early detection and effective treatment of TB plays important role in control of disease in any country.  Health seeking behavior and non-adherence to therapy has been cited as major barrier to the control of TB.  Non-adherence is a complex, dynamic phenomenon with a wide range of interacting factors impacting treatment taking behavior.  It poses a significant threat to both the individual patient and public health and is associated with higher transmission rates, morbidity, and costs of TB control programs.  Furthermore, it leads to persistence and resurgence of TB and is regarded as a major cause of relapse and drug resistance. , Keeping in view the present situation in Pakistan, a study was designed with the general objectives; wherein we investigated the knowledge, perceptions of (access to) TB treatment, and adherence to treatment among Karachi city population.
| Materials and Methods|| |
Descriptive cross-sectional study was done.
Community of Karachi having population of 20 million was selected to assess awareness of TB and patients of public sector hospitals in Karachi were selected.
A total sample size of 175 participants was taken, out of which 75 were community members while 100 were patients on DOTS treatment.
Non-probability convenient sampling was done.
Community members of both the sexes above 18 years of age and patients of both the sexes were included in the study. Those community residents and patients who have received health education program were excluded.
After selection of subjects from community and patients from DOTS center, their verbal consent was taken. They were asked questions and questionnaire were filled which had been translated into local language. Questions related to knowledge on TB types were included. The first question involves knowledge on TB in general; "TB can easily be cured if you take the right treatment". The second, "If you have TB it takes many months to be cured" assessed knowledge on TB. The third question "what source of knowledge about TB". During the interview it was made clear to respondents which question addressed TB. In total, eight agree/disagree questions were presented to the respondent (correct = score 1, incorrect = score 0). The total score therefore ranges from 0 to 8, with higher scores indicative of greater knowledge.
The results also revealed specific perceptions and attitudes toward TB within this community. People think that irresponsible individuals who do not take their treatment are mainly to blame for spreading TB. Besides blaming those individuals, they accuse them of hiding their TB status for fear of what others might say. They also think that people who acquire TB through drinking and smoking are getting what they deserve and that TB patients are less respected within the community. This suggests that people might be subjected to a high level of stigmatization. These items were included in the questionnaire to investigate the extent to which people in this community share these attitudes and perceptions.
Statistical analyses of attitudes and perceptions toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types consisted of frequency counts and percentages. Regression analysis and logistic regression analysis were performed to test whether differences in age, gender, and education level led to different knowledge scores and different attitudes and preferences toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 16.0.
The Dow University Ethical Review Committee has approved this research project. Every questionnaire attached with consent form. No sharing of information and data of study was the property of investigator. Result of study was communicated to health department. The complete process of data collection and analysis was approved by ethical committee of Dow University.
| Results|| |
Mean age of data set was 42 years (standard deviation (SD) 2.1) and age of the subjects ranged from 19 to 70 years. More than half (57%) of participants were male. Nearly half (46%) of the participants were illiterate. Nearly two-third (73%) were single on marital status. More than half (60%) were blue collar (manual labor) occupation [Table 1].
More than one quarter (35%) of participants heard about TB. Regarding source of knowledge, nearly half (40%) of the participants gained knowledge about TB from media. Most of respondents had correct response regarding TB symptoms, spread, prevention, and control of TB [Table 2].
|Table 2: Knowledge level regarding tuberculosis among study participants|
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Results show that 75% believe people with TB tend to hide their TB status because they are afraid of what others may say, 68% believe it is mainly the irresponsible patients who do not take their treatment that are to blame for spreading TB, 46% believe that people who get TB through drinking or smoking get what they deserve, and 34% believe that if you have TB people do not respect you [Table 3].
Fifteen percent believe "they stick to the rules of treatment", and it is the most important thing that helps TB patients stay on treatment for 6 months, followed by "they want to show others that TB is like any other curable disease" (14%) and "they don't drink or smoke while on treatment" (12%) [Table 4].
|Table 4: Perceptions toward adherence regarding tuberculosis treatment among TB patient|
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Adherence of TB treatment
More than half (57%) of the participants were afraid of taking TB medicine, nearly half (45%) were taking medicine under supervision [Table 5].
| Discussion|| |
Public and private mix (PPM) model was initiated with DOTS program in 2005; objective of this program was to access the TB treatment near patient's residence. It also helps to increase the awareness about TB in the general population. Major issue raised in this model was that there is lack of incentive to private practitioners for providing services to patient. It is not surprising that these private practitioners have been developing a variety of means to attract patients in order to generate more revenues by providing more services and selling more medicines. 
In Pakistan, health education programs on awareness of TB have made good impact on people's knowledge about TB. In this study, we have found that most of the people (64%) don't know about transmission of TB and only 32% knew it was transmitted through contact with TB patient, but the knowledge regarding TB is associated with inappropriate health seeking behavior. Only 18.7% of participant knew that cough and fever are high risk for TB and transmitted to other people. The negative attitude on TB among general population after the health education program raised our concern on the health educations regarding TB in Pakistan: The question arises is that how this campaign is successful and what is the cost-effective way to reduce burden of TB?
In this study, only 30% of participants know that hygienic practice adopted by people can prevent TB transmission. Same results were found in several other studies was that lack of knowledge is a significant predictor of delay diagnosis of TB. , Another study was conducted in China also found that inappropriate education were major factors for prevalence of TB in the community. 
Treatment compliance is a complex phenomenon, where multitude of factors play vital role in describing the behavior of the patient about TB. Similar findings were found in the study which was conducted in Madagascar showing that knowledge was a significant factor for noncompliance.  Patient usually feels better and stops taking medicine initially after start of treatment because the medicine rapidly reduce the number of tubercle bacilli (bacillary load) in the body; this leads to noncompliance of TB patient. Various studies also found that improvement in the general condition and stop of treatment was among reasons for default. ,
Relationship between healthcare provider and patient is a core determinant of compliance to ATT. Relationship include negative attitude towards TB patient, bad experiences of TB patients towards the health center, availability of medicines, and lack of transport to access the health center as found in other studies. ,
Though our study has pointed out various factors that can affect the knowledge and compliance to ATT, but results should be interpreted cautiously as there are certain limitations. These include; patients were recruited from selected hospital, which might not truly reflect the vision of the whole population in Pakistan. Another limitation is that information is dependent on self-reported data and the survey on healthcare seeking behavior was based on recall history. To minimize recall bias, questionnaires were pretested and all questions were set to be easily understood; data collector were carefully trained and supervised.
We have tried to address this limitation by taking time from patient initially by asking them about their spare time for interview, so that the interview was conducted on the convenience of the participants and that helped us in exploring the perceptions and insight information regarding adherence to ATT.
The results are suggestive of a high level of stigmatization; 57% of respondents believe people with TB tend to hide their TB status because they are afraid of what others may say. People think that irresponsible individuals who do not take their treatment are mainly to blame for spreading TB. Besides blaming those individuals, they accuse them of hiding their TB status for fear of what others might say. They also think that people who acquire TB through drinking and smoking are getting what they deserve and that TB patients are less respected within the community. While research shows that the increased TB incidence and prevalence during the last decade is mainly due to population increase where TB is most prevalent, increase of poverty  and most people within this community believe it is mainly the irresponsible patients who do not take their treatment that are to blame for spreading TB. Also the finding that respondents believe people who drink and smoke "get what they deserve" indicates blame and potential stigmatization.
To increase awareness about TB, Government or the NTCP must highlight on dissemination of knowledge through electronic media in order to combat this highly infectious disease to get rid from the population. Importance of early diagnosis and early initiation of treatment are major component of health education to prevent transmission of TB. Work should be done to make people aware of risk of TB; so as to know that it is a curable disease with adequate treatment, but if not treated properly it may spread to other people and it results in disability and death of the individual. Poverty eradication programs should have component of health education for hygienic and healthy living.
The results of this study show that while TB "lay experts" knowledge seems fairly good, their perceptions suggest that stigma may play a significant role in case finding and case holding. Findings from this study are important in improving the societal supports to TB patients. It would seem, therefore, that community education should focus on improving attitudes and perceptions, thus potentially reducing stigma. It requires a patient centered approach, which starts with interventions targeting the intrapersonal level (empowerment, self-help, advocacy, and support group) to empower TB patients.
| Conclusion|| |
Most of the subjects were unaware of TB that seems to be due to their illiteracy and those who knew had got the knowledge from media, but the majority of the patients who were on DOTS were found to be satisfied. TB awareness among Pakistani population is low and need to be improved through combined efforts of government and health professionals. Burden of TB in Pakistan has not changed significantly because of low literacy rate and lack of awareness. Attitude towards TB treatment was negative as health professionals were giving health education to their patients.
| Acknowledgement|| |
The author thanks Prof. Dr. Nighat Nisar for supporting to conduct the study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]