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ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 25-28

Study on default and its factors associated among Tuberculosis patients treated under DOTS in Mayurbhanj District, Odisha


Department of Epidemiology and Parasitic Diseases, National Center for Disease Control, New Delhi, India

Date of Web Publication4-Jun-2015

Correspondence Address:
Ms. Sudipta Basa
176/E, 2nd Floor, Prajapat Nagar, Gautam Nagar, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.158125

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  Abstract 

Background: Defaulting from tuberculosis (TB) treatment has been one of the major obstacles to treatment management and an important challenge for TB control. Understanding of various factors accounting for treatment default could help to achieve better compliance from patients. Thus the aim of the study is to estimate number of defaulters out of total TB patients registered under DOTS from January to June 2005 and to study the reasons for default in Mayurbhanj district, Orissa. Materials and Methods: A cross-sectional study was done by interviewing 41 defaulters using pre-tested semi-structured questionnaire to elicit reasons for default. Data was analyzed using Epi-info-(3.5.1), to find statistical significance among the variables. Results: Of the total 41 defaulters among 550 patients registered, only 31 could be interviewed, 10 were untraceable at the address provided. Default rate in our study was 7.5%. Majority of patients (73%) had defaulted during intensive phase of the treatment. A higher default rate associated with age group of 40-60 years, males and employed groups. The main reasons for default was due to drug toxicity (42%), feeling better so discontinued (35.5%), alcoholism (19.4%), migration (6.45%), wrong ideas (6.45%), DOTS provider absent (3.2%), DOTS provider rudeness (3.2%), and other reasons (9.7%), which includes family problems, timing inconvenient, and carelessness. Risk factors significantly associated were male, age, alcoholism, and distance of more than 5 km from treatment center. Conclusions: The majority of patients have defaulted in intensive phase of treatment. All efforts should be made to retrieve these patients and return them to treatment to achieve the expected goal of Revised National Tuberculosis Control Programme (RNTCP).

Keywords: Default, factors associated, tribal setting, tuberculosis


How to cite this article:
Basa S, Venkatesh S. Study on default and its factors associated among Tuberculosis patients treated under DOTS in Mayurbhanj District, Odisha. J Health Res Rev 2015;2:25-8

How to cite this URL:
Basa S, Venkatesh S. Study on default and its factors associated among Tuberculosis patients treated under DOTS in Mayurbhanj District, Odisha. J Health Res Rev [serial online] 2015 [cited 2018 Dec 13];2:25-8. Available from: http://www.jhrr.org/text.asp?2015/2/1/25/158125


  Introduction Top


Tuberculosis (TB) is a highly infectious disease, which continues to be an important public health problem worldwide, with 8-10 million new cases added every year. [1]

The disease is caused by the bacillus Mycobacterium tuberculosis and spreads through the air/droplet infection. It primarily affects lungs and causes pulmonary TB. It can also affect intestine, meninges, bones and joints, and other tissues of the body. [2]

India accounts for 28% of the global burden of TB. Two out of every five Indians are infected with the TB bacillus. [3] Each patient with infectious pulmonary TB disease can infect 10-15 persons in a year. In India, TB kills more adults in the most productive age group (15-54 years) than any other infectious disease. A patient of TB takes an average of three or four months to recuperate, losing that much income. TB has devastating social cost as well as data suggest that each year; more than 300,000 children are forced to leave schools because their parents have TB, to supplement the family income and to help to take care of siblings. [1],[4],[5] Studies indicate that while men have to deal with stigma at their work places and in the community, women are ostracised in the household and the neighborhood. [6]

Defaulting from treatment has been one of the major obstacles to treatment management and an important challenge for TB control. Inability to complete the prescribed regimen and which is quite common in self-administered treatment and poor patient adherence to the treatment regimen are major causes of treatment failure and of the emergence of drug-resistance. [7] Over the years, there has been increasing emphasis on Directly Observed Treatment short course (DOTS) strategy for TB control in India. Revised National TB control program (RNTCP) adopted DOTS strategy for TB control in India. This has increased success rate of the coverage as well as cure rate. One area of problem is reducing the efficiency of DOTS strategy is default rate. A strict adherence to Directly Observed Treatment is likely to minimize defaults and is therefore essential for the desired treatment success. [1],[2],[3]

Objectives

  • To estimate the number of defaulters out of total TB patients registered under DOTS in 1 st and 2 nd quarters of 2005 in Mayurbhanj District of Odisha
  • To study the reasons of default in these patients using a semi-structured questionnaire.



  Materials and methods Top


This is a cross-sectional study, which had been carried out in Mayurbhanj district of Odisha during June-July, 2006. The district compromises of 58% tribal population and 42% others. The district has been divided into seven TB Units. The secondary data was collected from District TB Office from various registers. Forty-one defaulters among 550 TB patients registered in 1 st and 2 nd quarters of 2005, covering all the seven TUs were included in the study, that is, 100% sampling. The case definition used was as per RNTCP guidelines: Default is defined as "a patient who at any time after registration has not taken anti-TB drugs for 2 months or more consecutively."

The patients were interviewed at their home. In case of patients who had migrated or died, their family members/nearest neighbors were interviewed. The pre-tested questionnaire was administrated in obtaining information about the patients' socioeconomic and demographic profile, literacy status, drinking habits, problems in taking drugs regularly, and various other reasons for default.

Data analysis was done with the help of statistical tools such as percentage and using Epi-info-(3.5.1). Chi-square test was used to evaluate significant difference between proportions, P < 0.05 was considered as statistically significant.

The interview was conducted after obtaining verbal consent from the patients. The ethical clearance for the study was obtained from ethical committee of institution of NCDC.


  Results Top


Out of 550 TB patients registered under DOTS in seven TB Units of 1 st and 2 nd quarter of 2005, 366 (66.5%) were male TB patients and 184 (33.5%) female TB patients. From the same cohort, 41 patients who defaulted from treatment, only 31 defaulters could be traced and interviewed (male 25, female 6). The overall default rate is 7.45%. The male patients (9%) show higher proportion of default as compared with female patients (4.3%) and was statistically significant (P value = 0.049), [Table 1].
Table 1: Genderwise distribution of defaulters


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In the age group of 40-60 years (10.7%), the default rate was higher followed by 20-40 years age group (8.1%) as shown in [Table 2].
Table 2: Agewise distribution of defaulters


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The defaulter rate was higher in employed group (7.9%), which consists of farmers and laborers as compared with unemployed group (6.4%). There was a higher proportion of defaulters in areas where treatment centers were more than 5 km (10.3%) away compared with places where it was in less than 5 km (5.5%) distance and was statistically significant [Table 3].
Table 3: Placewise (distance) distribution of defaulters


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Majority of defaulters were in intensive phase 30 (73%) as compared with continuation phase 11 (27%). Alcohol users show a higher default rate (10.3%) compared with nonusers (4.6%) and was statistically significant [Table 4].
Table 4: Alcoholism distribution of defaulters


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[Table 5] shows various reasons given by the patients for defaulting from treatment. A 42% patients defaulted due to drugs toxicity, that is, vomiting and head reeling followed by 35.5% patients who discontinued after feeling better, 19.35% due to alcoholism, 6.45% due to wrong ideas, 6.45% due to migration, 3.2% due to absence of DOTS provider, as well as 3.2% due to rude behavior of DOTS provider and other reasons (9.7%), which includes family problems, timing inconvenient, and carelessness.
Table 5: Distribution of defaulters reasons (n=31)


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  Discussion Top


The present study highlights the problem of default during intensive phase and the potential reasons associated with default among the defaulters who are tribals. The overall default rate of 7.45% was observed in our study [Table 1].

In this study males (9.0%) showed a high percentage of defaulting as compared with females (4.3%). A similar finding was highlighted by Chandrasekharan et al. in their study conducted in Tiruvallur district of Tamil Nadu. [8] Age distribution pattern in the present study was similar to other studies, which have shown that the peak levels of defaulting are in the age group of 45-59 years. In our study there was a high percentage of defaulters in the age group 40-60 years (10.7%) and the same has been reported by Chatterjee et al. in their study in a private hospital of Jamshedpur. [9] All the defaulters were tribals who were illiterate, and therefore lack of knowledge about the disease have resulted in noncompliance in our study. A similar finding was reported by Pandit et al. in their study conducted in Gujarat. [10]

This study brings into focus that the defaulter rate was higher in employed group (7.9%), which consists of farmers and laborers as compared with unemployed group (6.4%). The main reason behind defaulting in employed group is that they did not want to lose their daily wages as they have to travel distance more than 5 km to collect medicine, which made the timings very inconvenient, Chandrasekharan et al. and Jaggarajamma et al. have reported similar reasons. [8],[11]

Majority of the patients defaulted during Intensive Phase (73%) compared with Continuation Phase (27%) in our study. During this phase, symptoms usually subside and patients are likely to default. They do not realize the need to take the entire course of treatment because of lack of knowledge about the disease. The findings are similar to a study done by Chandrasekharan et al., which highlights 71% defaulted in Intensive Phase, illiteracy, and loss of wages were the additional factors present in the study. [8] Defaulting was more common among married males, which could have been avoided by enlisting family support for DOTS as reported by Vijay et al. in their study in Bangalore. [7] Family co-operation has been identified as a possible protective factor against defaulting in Ethiopia as reported by Ravlioghe et al.[12] Risk factors for default are gender, that is, male group (P = 0.05), age (P = 0.04), alcoholism (P = 0.01), and distance more than 5 km from treatment centre (P = 0.03) are significantly associated and are similar to the findings of various studies conducted in India and other African countries. [6],[7],[9],[12],[13],[14],[15]

This study has brought out the toxicity of drugs causing vomiting and head reeling as an important factor for treatment default (42%) as shown in [Table 5], which is in agreement with findings reported by Chandrasekharan et al. and Sukumaran et al. in their study. [8],[13] Second most important factor for defaulting in our study was started feeling better so discontinued (35.48%)-similar finding has been reported by Kaona et al. in Africa. [6] Missed doses due to alcohol addiction (19.35%) has been identified as an important factor in our study, which is similar to the findings by Vijay et al.[15] Migration (6.45%) is another important factor, which contributes to defaulting. Jaggarajamma et al. has reported a similar finding. [11] Migration is mainly due to occupational reasons. Irregular and incomplete treatment on account of migration is likely to increase the burden of TB in the community.

In our study seven deaths among the defaulters were reported, which was higher compared with three deaths reported in study conducted by Chandrasekharan et al.[8] Death occurred in five married males who were defaulters, which further adds to the socioeconomic repercussions of the disease on the family and the community at large.

Among the various reasons for defaulting, the important ones were DOTS provider absence (3.2%), DOTS provider rude behavior (3.2%), wrong ideas (6.45%), that is, switching over to other systems of medicine, family problems, inconvenient timing, and carelessness (9.7%) have been stated by patients, which were also reported in other studies. [9],[10]

Extra efforts such as counseling, supervision, home visits, and motivation to retrieve patients likely to default during the intensive phase and return them to treatment would have ensured a favorable treatment outcome. Besides the above, the DOTS provider and patients need to be educated properly to overcome problems during the treatment. Frequent meetings of DOTS provider with Medical Officers of health facilities are the need of the hour to address these challenges in addition to improved monitoring and supervision and health education at grassroot levels with special focus to difficult and tribal areas.


  Conclusion Top


This study has brought out potential factors/reasons contributing to nonadherence during the intensive phase of the treatment among the illiterate and underprivileged population. Currently, the RNTCP program of India has many components. Outreach workers, referral systems, regular patient followup, and DOTS procedure are prominent features of the initiative. However, a more comprehensive approach, incorporating easier access to drugs, good capacity building of health care providers, effective solutions addressing travel-related concerns, modification of lifestyle behaviors, and emphasizing on motivating and counseling patients are essential for treatment completion among patients.


  Acknowledgments Top


I extend with gratitude my sincere thanks to Dr. S. Venkatesh, Director, NCDC, Delhi, Dr. Ravi Kumar and Dr S Hossain (MPH Faculty) NCDC, Delhi, for their close guidance and encouragement during my research on this topic as an MPH student. I thank RNTCP Team, Mayurbhanj, for their support and help during data collection.



 
  References Top

1.
TB India (2006). RNTCP status report, RNTCP, Central TB Division. New Delhi: Ministry of Health and Family Welfare, Government of India; 2006.  Back to cited text no. 1
    
2.
Park K. Park′s Textbook of Preventive and Social Medicine. 18 th ed.Jabalpur: BanarsidasBhanotPublishers; 2005. p. 146-61.  Back to cited text no. 2
    
3.
Aggarwal SS, Aggarwal NS, Nagar SS, Makadia BK. Assessment of one year of RNTCP. Indian J Community Med 2004;XXIX: 164-5.  Back to cited text no. 3
    
4.
Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Consensus statement. Global burden of tuberculosis: Estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA 1999;282:677-86.  Back to cited text no. 4
    
5.
Harries AD, Maher D. TB/HIV: A Clinical Manual. Geneva: WHO Publication; 1996.  Back to cited text no. 5
    
6.
Kaona FA, Tuba M, Siziya S, Sikaona L. An assessment of factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment. BMC Public Health 2004;4:68.  Back to cited text no. 6
    
7.
Vijay S, Balasangameswara VH, Jagannatha PS, Saroja VN, Kumar P. Defaults among TB patients treated under DOTS in Bangalore City: A search for Solution. Indian J Tuberc 2003;50:185-95.  Back to cited text no. 7
    
8.
Chandrasekaran V, Gopi PG, Subramani R, Thomas A, Jaggarajamma K, Narayanan PR. Default during the intensive phase of treatment under DOTS programme. Indian J Tuberc 2005;52:197-202.  Back to cited text no. 8
    
9.
Chatterjee P, Banerjee B, Dutt D, Pati RR, Mullick AK. A comparative evaluation of factors and reasons for defaulting in TB treatment in the states of W. Bengal, Jharkhand and Arunachal Pradesh. Indian J Tuberc 2003;50:17-22.  Back to cited text no. 9
    
10.
Pandit N, Choudhary SK. A study of treatment compliance in directly observed therapy for tuberculosis. Indian J Community Med2006;31:241-3.  Back to cited text no. 10
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11.
Jaggarajamma K, Muniyandi M, Chandrasekaran V, Sudha G, Thomas A, Gopi PG, et al. Is migration a factor leading to default under RNTCP? Indian J Tuberc 2006;53:33-6.  Back to cited text no. 11
    
12.
Raviglione MC, Harries AD, Msiska R, Wilkinson D, Nunn P. Tuberculosis and HIV: Current status in Africa. AIDS 1997;11(Suppl B):S115-23.  Back to cited text no. 12
    
13.
Sukumaran P, Venugopal KP, Manjooran RS. A social study of compliance with DOTS. Indian J Tuberc 2002;49,205 7.  Back to cited text no. 13
    
14.
NinanBS. Determinates of treatment non-compliance among pulmonary TB patients in RNTCP DOTS, Trivandrum, Kerala, India. Indian J Tub 2001. Available from: http://www.dspace.sctimst.ac.in/jspui/handle/123456789/2254. [Last accessed on 2015 March].  Back to cited text no. 14
    
15.
Vijay S, Balasangameswara VH, Jagannatha PS, Saroja VN, Kumar P. Treatment outcome and two and half years follow-up status of new smear positive patients treated under RNTCP. Indian J Tuberc 2004;51:199-208.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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