Treatment Adherence | Cochrane Equity

Multiple Factors Influence Patient Treatment Adherence for Tuberculosis

Why is it important to understand the factors influencing TB treatment adherence?

Tuberculosis (TB) is a global health concern which kills nearly two million people per year. Various interventions have been developed to improve treatment completion, however, poor adherence to treatment remains common. The duration of treatment is often the most noticeable barrier, with patients following regimens lasting 6 months or longer. However, there are many other barriers to treatment adherence that are not well understood and as a result, effective solutions are difficult to find. An understanding of barriers will facilitate proper treatment adherence and prevent increased drug resistance, mortality, and prevalence of TB. This review identified barriers to treatment adherence

What factors improve patient treatment adherence?

Increased visibility of TB programs within the community may increase overall knowledge and improve attitudes towards TB
Increased accessibility to information/education about the disease and its treatment to patients and communities
Increased support from social networks
Minimization of cost and unpleasantness associated with clinic visits
Increased patient centredness of interactions between providers and clients
Address ‘‘structural’’ and ‘‘personal’’ factors, for example through micro-financing and other empowerment initiatives
Provide more information about the effects of medication to reduce the risk of patients becoming nonadherent when experiencing treatment side effects

Equity - Do these factors improve treatment adherence for the disadvantaged?

The studies included in the review were conducted in high-, middle-, and low-income countries, with greater prevalence of TB in the lowest income countries
The factors were derived from studies analyzing the impact of place of residence, socioeconomic status, access to information, religion, immigration status, social support and gender on treatment adherence
Studies including specific disadvantaged groups such as those who are homeless, HIV+ individuals, and injection drug users were included in the review
Pregnant mothers were included in the review
Children under the age of 15 were not included in the review

Intervention Delivery and Collection of Data

Conventional curative TB treatment regimens through either DOT or patient-administered therapy as well as preventative treatments were included
The review was focused not on the TB treatment itself but on the factors which influence patient adherence to such treatment
Data was collected via focus group discussions, surveys, in-depth and semi-structured interviews, participant and non-participant observations, and notes from fieldwork journals

Population and Setting

TB patients, volunteers, nurses, and physicians were included in the studies
Both men and women were interviewed/surveyed
Majority of studies limited age to 18+ with a few studies starting at 15+
Studies were conducted in low-, middle-, and high-income countries

Summary of Findings Table:

Patient or population: TB patients, volunteers, nurses, and physicians (both men and women, ages 15 and up)
Setting: Countries with low to high TB prevalence
Intervention: Conventional TB treatment through either DOT or patient-administered therapy, review did not provide information on exact antibiotics used or how long
Comparison: Patient treatment adherence across multiple factors

Table 1: Factors Influencing TB Treatment Adherence

Factor	Impact	No of studies (participants)^a	Quote
Organisation of Treatment and Care for TB Patients	Increased distance between place of residence and clinic resulted in lowered adherence. Other factors such as waiting times, queues, lack of privacy, and inconvenient appointment times negatively impacted adherence.	28 (9,666)	"The patients do not have the adequate means to go to the health centre to take their drugs. Thee just have camel, donkey or carts... And sometimes, the state of some patients prevents them from using these" (male family member of TB patient, Burkina Faso)
Interpretations of illness and wellness	Many patients had stopped treatment after they initially felt improved sympomts and thought they were cured.	18 (3640)	"... When I feel better, I don't take the tablets. Only when I feel pain" (completer, South Africa)
Financial Burden of TB Treatment	Many patients cited direct and indirect costs of treatment as deterrents from attending treatment. Patients often prioritized work over treatment as they felt they could not afford to do both.	24 (7020)	"It's a bit difficult, because, as I told you, the radiography and the control smear cost more than 100B; the consult costs 15B... it will cost me almost 150B to start treatment again. At this moment, I don't even have the money for the trip to the hospital..." (male TB patient, Bolivia)
Knowledge, Attitudes, and Beliefs about TB Treatment	Adherence appeared to improve when patients understood the importance of completing treatment. Patients beliefs about the efficacy of treatment (whether positive or negative) may impact adherence.	31 (10,001)	"... And when you take medications, these bugs will die, he told me. The medications kill the bugs. This is what I've been told, but I'm not sure. It seems uncertain to me. Because the pills didn't help me..." (female TB patient, Bolivia)
Law and Immigration	Immigration status either motivated or deterred patients from pursuing treatment. Some patients cited fear that thier illegal status would be revealed oce they attended treatment.	6 (1963)	"Because the nurse tells us that here they have a record of people who have TB, and when they go to apply for a job it shows up on the record that they have TB and it was untreated, they need [the completion record] for the job" (male Vietnamese refugee patient, US)
Personal Characteristics and Adherence Behaviour	Marginalized peoples (i.e. homless, substance users, ethnic minorities, seniors, individuals with mental illness, etc) were perceived to have a higher risk of non-adherence. Non-adherent patients were labeled as 'lazy' in some instances. Personal agency played a role in adherence with self-administered therapy and those who developed their own reminders adhered readily.	24 (9396)	"How would someone who starts drinkign early in the morning visit the clinic? Some patients consume alcohol daily. They would rather decide to interrupt their treatment, than discarding their drinking habit" (male respondent, South Africa)
The Influence of Side Effects on Treatment Adherence	Some patients reported stopping medications due to adverse side effects.	13 (4002)	"... I don't want to take these pills, because they make me sick, they hurt me..." (female TB patient, Bolivia)
Family, Community, and Household Influences	Stigma within community and amongst family members and peers may decrease treatment adherence. Family support, both financial and emotional, had a positive influence on adherence.	29 (7262)	"... It was very important, I had my sister and my ex-girlfriend and it was really, really important to have someone, you know, to give you support especially when you don't know much about the disease" (male TB patient, UK)

a - The number of participants was determined via the summation of the reported number of participants in each individual primary study cited in the section. Participant data from cited Masters theses and PhD dissertations could not be determined.

Relevance of the review for disadvantaged communities

Findings	Interpretation
Equity – Which of the PROGRESS groups examined
The studies included in this review were conducted in Africa (14), North America (9), South (8) and East Asia (8), Latin America (2), and Europe (2), in a range of low- to high-income countries.	This review analyzed the various factors influencing patient treatment adherence. Poor treatment adherence contributes to the development of drug resistant forms of TB particularly in low-income countries where prevalence is high.
Patient adherence was negatively impacted by distance to clinical facilities. The review found that patient adherence decreased with increased distance between the patient’s residence and the nearest clinic. One study found that access to healthcare was better in urban compared to rural areas.	Increased distance between the patient’s home and the nearest clinical setting may lead to an increase in cost associated with commuting to the treatment centre. Patients may feel deterred from pursuing treatment if the perceived costs outweigh the benefits. Treatment should be planned as to enable optimal access to clinical care. Distance to care provider should be a factor considered in developing treatment plans.
The financial burden of treatment had a significant impact on patient adherence. Both the direct and indirect costs of treatment had an impact on adherence. Many patients cited their poor adherence or lack thereof to the high cost of medication and in cases where medication was covered, incidental fees such as the cost of x-rays deterred patients.	Treatment plans need to consider the financial burden that may be imposed on the patient and how this impacts adherence to the treatment regimen. An understanding of the costs both directly and indirectly associated with treatment will allow for better planning of treatment and improved adherence.
Many patients either felt pressure to hide their TB diagnosis at the workplace in fear of dismissal or to stop treatment altogether in order to continue to work full-time. Particularly in rural areas, patients felt that they were forced to choose between continuing treatment and making a living, as it was often too difficult to combine the two. The treatment was perceived as too expensive to afford without working however, if they sought work, they were unable to attend treatment.	Treatment needs to be more cost effective and accessible to patients in order to alleviate the stress associated with missing work to attend treatment. Information regarding TB should be more accessible in order to eliminate stigma associated with the disease. Reduced stigma may improve adherence as less patients would fear dismissal as a result of their diagnosis.
Marginalized individuals were perceived to have a greater risk for non-adherence by both treatment providers and patients. Individuals experiencing substance use disorder, mental illness, and homelessness were all deemed to be at a greater risk for nonadherence to treatment.	Strong social support systems facilitate treatment adherence and when these systems are lacking, adherence may deteriorate. Social programs providing support to marginalized individuals with TB may improve adherence and overall treatment outcome.
Socioeconomic status and education impacted adherence to treatment. Wealthier and more educated patients were deemed more likely to adhere to treatment whereas illiterate patients were deemed more likely to default.	Greater access to information is needed, especially in poorer and isolated communities where TB prevalence is high.
Refugee/Immigration status had an impact on adherence. Some studies showed that refugees with latent TB felt more motiviated to attend treatment in order to obtain certification of preventative treatment. Other studies indicated that undocumented immigrants feared that attending treatment would reveal their illegal residence status.	Treatment should be accessible regardless of immigration status. Reducing the fear of persecution may improve adherence.
Gender inequality impacted treatment adherence. Some studies found that in certain countries, TB status could affect marriage (increased risk of divorce, husband taking a second wife, forced move to natal home).	The stigma associated with TB has a particular impact on adherence especially with regards to women and their rights. Reduced stigma may allow women to pursue treatment without fear of marital repercussions. Treatment plans and guidelines need to be developed with gender equity in mind.
Equity Applicability
The review analyzed multiple factors associated with equity in treatment.	Multiple factors such as socioeconomic status, residence, gender, education, etc need to be taken into consideration when developing treatment programs as they have an impact on the adherence to and effectiveness of said programs.
Cost-equity
This review found that cost had a significant influence on adherence.	Treatment programs should be developed as to minimize the direct and indirect cost for the patients accessing them. Lowered costs may improve adherence and as a result lower the prevalence, drug resistance, and mortality rate of TB in certain countries.
Community/Stakeholder Preferences
Multiple studies found that community attitudes/beliefs had an impact on adherence	Community based TB treatment programs may improve overall adherence to treatment.

Comments on this summary? Please contact Jennifer Petkovic.

This summary was prepared by Nicholas Lebel.