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  • Research note
  • Open Access

Non-adherence to anti-tuberculosis treatment, reasons and associated factors among TB patients attending at Gondar town health centers, Northwest Ethiopia

BMC Research Notes201811:691

https://doi.org/10.1186/s13104-018-3789-4

  • Received: 2 July 2018
  • Accepted: 25 September 2018
  • Published:

Abstract

Objective

The aim of this study was to assess the prevalence of non-adherence to anti-tuberculosis treatment, reasons and associated factors among TB patients attending at Gondar town health centers.

Result

A total of 314 participants were included with the response rate of 97.5%. The mean age of participants was 35.94 (SD ± 13.83) years. The overall rate of non-adherence to anti-TB treatment was 21.2% (95% CI 17.2, 26.1). Continuation phase of treatment (AOR = 2.27, 95% CI (1.54, 5.94)), presence of more than one co-morbidity (AOR = 6.22; 95% CI (2.21, 17.48)), poor knowledge about TB and anti-TB therapy (AOR = 4.11; 95% CI 1.57, 10.75), poor patient-provider relationship (AOR = 4.60, 95% CI 1.63, 12.97), and alcohol intake (AOR = 5.03; 95% CI 1.54, 16.40) were significantly associated with non-adherence. Forgetting 40 (23.1%), Being busy with other work 35 (20.2%), and being out of home/town 24 (13.9%) were the major reasons of participants for interruption of taking anti-TB medications.

Keywords

  • Prevalence
  • Reasons
  • Non-adherence
  • Tuberculosis treatment
  • Ethiopia

Introduction

Tuberculosis (TB) is airborne infectious disease caused by Mycobacterium tuberculosis [1]. It is one of the ten top causes of death worldwide from curable infectious diseases. Globally there were estimated 10.4 million new TB cases, and 600,000 new cases with resistance to rifampicin, 490,000 had multidrug-resistant tuberculosis (MDR-TB) cases and 1.7 million people died from TB [13].

The main risk factors for developing active TB case are human immunodeficiency syndrome (HIV) infection, low socioeconomic status/poverty, alcoholism, homelessness, crowded living condition, diseases that weaken the immune system, migration from country with high number of cases, and health-care workers [4]. Tuberculosis non-adherence is the major challenge in TB treatment which leads multidrug as well as extended drug-resistant TB [5, 6]. Combating non-adherence is the key and cornerstone of anti TB treatment. The prevalence of non-adherence to anti-tuberculosis treatment is 50% India, 15.5% Thailand, 24.7% and 24.5 South Ethiopia [710].

The main reasons for non-adherence in anti-tuberculosis treatment are drug side effects, forgetting to take medication, be away from home, missing date of appointment, lack of transportation cost, lack of social support, poor communication between patient and healthcare providers, and stock out of medicines [1113]. Non-adherence to anti TB treatment results in increased length and severity of illness, death, disease transmission and drug resistance. It has great economic impact in terms of cost to patients as well as the health care system [13, 14].

Adherence to long course TB treatment is complex, dynamic phenomenon with wide range of factors impacting on treatment taking behaviors [15]. Even though there is wide coverage of DOTs program in Ethiopia, there is paucity of evidence on rate, reasons and associated factors of non-adherence on anti TB treatment particularly in the study area. Therefore the present study determines prevalence, reasons and associated factors of non-adherence of anti TB treatment among TB patients.

Main text

Study design and setting

Institutional based cross-sectional study design was conducted among TB patients from May to June 2017 at Gondar town health centers. Gondar town is found about 737-km away from Addis Ababa. In the town, there are one governmental specialized hospital, one private hospital and eight governmental health centers which serve for more than five million populations. Maraki, Polly, and Azezo health centers were selected. In these health centers, there were around 713 TB patients.

Source population

All TB patients who were on anti TB treatment in Gondar town health centers were considered as source population.

Inclusion/exclusion criteria

All TB patients who took anti TB medication at least for 1 month were included in the study, whereas TB patients who were seriously ill and or unable to hear and speak were excluded.

Sample size and sampling procedure

The sample size was determined using single population proportion formula (n = [(Zα/2)2 × P (1 − P)]/D2) with the assumption of 95% level of confidence and 5% marginal error. Prevalence of non-adherence to anti TB treatment was taken 24.5% [10]. Taking 10% nonresponse rate the required sample size was 314. Using simple random sampling three health centers were selected. Proportional allocation method TB patients were taken from selected health centers (Maraki health center 88, Polly health center 110, and Azezo health center 116) then each study participant was selected using systematic random sampling. Sampling interval (K) was ~ 3 in each health center thus every three participants were interviewed based on their order of arrival.

Data collection tools and procedures

Data was collected by using pretested structured questionnaire adapted from different literatures [1012]. The questionnaire has socio-demographic information, characteristics of tuberculoses and anti- tuberculoses treatment, reasons for interruption taking medications, knowledge and attitude towards tuberculosis and anti-TB treatment, patient-provider relationship, and behavioral factors. Possible reasons for interruption of taking medications were listed with additional open ended option. Questions about interruption of taking medications were asked while participants report missed medications. There were nine knowledge, seven attitude and eight patient provider relationship questions. The correct responses were coded 1 and the incorrect responses coded 0 then the correct answers were added then participants who scored mean and above of the questions were labeled good knowledge, favorable attitude, and good patient-provider relationship (Additional file 1). Internal consistency of the questionnaire found good (Cronbach’s alpha 0.67). The inter-rater reliability was Cohen’s Kappa 0.65. The sensitivity, specificity, and correct classification were 98.3%, 71.2% and 85.0% respectively. Non-adherence was assessed based on number of pills reported to have been actually taken 1 month prior to data collection period divided by number of prescribed pills multiplied by 100%. Patients who missed ≥ 10% of the total prescribed dose were considered non-adherent. Data were collected by four trained BSc nurses through interviewer-administered and reviewing their medical records.

Data quality control technique

Pretest was conducted among 5% of the sample size before actual data collection and some modification was done. The questionnaire was first prepared in English and translated to local language Amharic and back to English for its consistency. One day training was given for data collectors and supervision was conducted on daily basis throughout data collection.

Operational definition

Non-adherent

Patients who missed ≥ 10% of total prescribed dose were considered non-adherent [10, 16].

Knowledgeable, favorable attitude, and good patient-provider relationship

Those respondents who scored points at mean and above for the knowledge, attitude, and patient-provider relationship questions respectively.

Alcohol intake

History of alcohol intake since time of starting anti-TB treatment.

Comorbidity

Presence of any of chronic disease along with TB.

Data processing and analysis

Data were checked for its completeness, coded and entered into Epi info Version 7 and exported to SPSS version 20 for analysis. Descriptive statistics were generated including frequency, percent, mean median, and standard deviation (SD). Tables and bar graph were used to display the findings. Univariate logistic regression was used to identify factors associated with non-adherence to tuberculosis treatment. Variables at P ≤ 0.2 in bivariate analysis were taken into multivariate logistic regression model to control possible confounders. Crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% CI were calculated. Variables at P-value < 0.05 in multivariate logistic regression model were considered statistically significant, and odds ratios with corresponding 95% confidence intervals were reported as the measures of the degrees of association.

Results

Socio-demographic characteristics of participants

Total of 314 participants were interviewed with 97.5% response rate. The mean age of participants was 35.94 (SD ± 13.83) years. More than half, 166 (54.2%), of participants, were males, 135 (44.1%) single and 193 (63.0%) were orthodox christians. Two-thirds 193 (63.0%) were Amhara by ethnicity. majority, 256 (83.7%), and a quarter, 75 (24.5%), were urban dwellers and grade 9–12 by education, respectively. One hundred forty-five (47.4%) were had distance of 3–5 km from TB clinic and more than half 158 (51.6%) had > 30 min traveling time (Table 1).
Table 1

Socio-demographic characteristic of TB patients attending TB clinic in health centers at Gondar town, Northwest Ethiopia, 2017 (n = 306)

Variable

Frequency (n)

Percent (%)

Sex

 Male

166

54.2

 Female

140

45.8

Age

 18–28

75

24.5

 29–38

61

19.9

 39–48

83

27.2

 ≥ 49

87

28.4

Marital status

 Single

135

44.1

 Married

117

38.2

 Divorced

36

11.8

 Widowed

18

5.9

Religion

 Orthodox

193

63.0

 Protestant

58

19.0

 Muslim

55

18.0

Ethnicity

 Amhara

234

76.5

 Tigrie

40

13.0

 Kimant

32

10.5

Residence

 Urban

256

83.7

 Rural

50

16.3

Educational status

 Unable to read and write

51

16.7

 Able to read and write

65

21.2

 Grade 1–8

49

16.0

 Grade 9–12

75

24.5

 Diploma

27

8.8

 Degree and above

39

12.8

Occupational status

 Government employee

119

38.9

 Merchant

35

11.4

 Farmer

25

8.2

 Housewife

47

15.4

 Student

27

8.8

 Daily laborer

29

9.5

 Unemployed

24

7.8

Income (Ethiopian Birr)

 ≤ 1000

134

43.8

 1001–2000

81

26.5

 2001–3000

50

16.3

 > 3000

41

13.4

Distance from TB clinic (single trip) (km)

 < 3

70

22.9

 3–5

145

47.4

 > 5

91

29.7

Type of transportation to the TB clinic

 Walking/foot

84

27.5

 Public transport

222

72.5

Traveling time (single trip) (min)

 ≤ 30

148

48.4

 > 30

158

51.6

Cost of traveling (single trip) (n = 222) (Ethiopian Birr)

 ≤ 10 Birr

114

51.4

 > 10 Birr

108

48.6

The overall level of non-adherence to anti-TB therapy

In this study, the rate of non-adherence to anti-TB therapy was 65 (21.2%) (95% CI 17.2, 26.1). The rate is higher (47.0%) among return after default treatment category and lower (19.1%) among new category.

Participants’ reasons for interruption of taking anti-TB medications

Participants were asked about reason of interruption of taking medications while they report missing any number of medications. Seventy participants were reported missed anti-TB medications. Most of participants report more than one reason for missing. Forgetting 40 (23.1%), Being busy with other work 35 (20.2%), and being out of home/town 24 (13.9%) were the major reasons of participants for interruption of taking anti-TB medications (Fig. 1).
Fig. 1
Fig. 1

Reasons for interruption of taking anti-TB medications of participants attending TB clinic in health centers at Gondar town, Northwest Ethiopia, 2017 (n = 173)

Factors associated with non-adherence to anti-TB therapy

In this study; treatment phase, co-morbidity, knowledge, patient-provider relationship, and alcohol intake were significantly associated factors.

Participants who were in continuation phase of treatment were 2.27 times (AOR = 2.27, 95% CI (1.54, 5.94)) more likely non-adhere to their anti-TB therapy than those in intensive phase. Participants with more than one co-morbidity were 6.22 (AOR = 6.22; 95% CI (2.21, 17.48)) more likely to be non-adhere than participants with no or one co-morbidity. Furthermore, participants who had poor knowledge about TB and anti-TB therapy were 4.11 times (AOR = 4.11; 95% CI 1.57, 10.75) more likely to be non-adherent compared with participants with good knowledge. In addition, participants who had poor patient-provider relationship were 4.6 times (AOR = 4.60, 95% CI 1.63, 12.97) as likely be non-adherent as who had good patient-provider relationship. The odds of anti-TB non- adherence was found high among participants who were alcohol intake history (AOR = 5.03; 95% CI 1.54, 16.40) (Table 2).
Table 2

Univariate and multivariate analysis for non-adherence to anti-TB therapy among TB patients attending TB clinic in health centers at Gondar town, Northwest Ethiopia, 2017 (n = 306)

Variables

Adherence status

COR (95% CI)

AOR (95% CI)

P-value

Adherent

Non adherent

Sex

 Male

133

33

0.84 (0.48, 1.45)

  

 Female

108

32

1

  

Age

 18–28

62

13

1

1

 

 29–38

48

13

1.29 (0.55, 3.04)

3.22 (0.68, 15.17)

0.139

 39–48

70

13

0.89 (0.38, 2.05)

0.83 (0.18, 3.88)

0.808

  ≥ 49

61

26

2.03 (0.96, 4.32)

2.44 (0.53, 9.41)

0.272

Marital status

 Single

113

22

0.24 (0.09, 0.69)*

0.11 (0.01, 1.60)

0.105

 Married

91

26

0.36 (013, 0.99)*

0.09 (0.01, 1.30)

0.077

 Divorced

27

9

0.42 (0.13, 1.38)

0.15 (0.01, 3.22)

0.228

 Widowed

10

8

1

1

 

Residence

 Urban

205

51

0.73 (0.36,1.46)

  

 Rural

36

14

1

  

Educational status

 Unable to read and write

41

18

0.59 (0.16, 2.12)

1.28 (0.21, 7.62)

0.789

 Able to read and write

45

20

2.62 (0.96, 7.12)

1.12 (0.20, 6.37)

0.899

 Grade 1–8

44

5

1.24 (0.40, 3.80)

0.41 (0.06, 3.01)

0.381

 Grade 9–12

65

10

1.01 (0.35, 2.93)

2.12 (0.34, 13.11)

0.420

 Diploma

22

5

1.10 (0.30, 4.07)

1.48 (0.19, 11.66)

0.710

 Degree and above

32

7

1

1

 

Income (Ethiopian Birr)

 ≤ 1000

102

32

1

1

 

 1001–2000

60

21

1.12 (0.59, 2.12)

1.65 (0.50, 5.51)

0.414

 2001–3000

43

7

0.52 (0.21, 1.27)

0.47 (0.09, 2.38)

0.365

 > 3000

36

5

0.44 (0.16, 1.22)

0.12 (0.01, 1.30)

0.081

Distance from TB clinic (single trip) (km)

 < 3

65

5

1

1

 

 3–5

121

24

2.58 (0.94, 7.08)

1.83 (0.38, 8.78)

0.450

 > 5

55

36

8.51 (3.12, 23.18*

4.30 (0.80, 23.16)

0.090

Type of transportation to the TB clinic

 Walking/foot

72

12

1

1

 

 Public transport

169

53

1.88 (0.95, 3.73)

1.80 (0.54, 6.01)

0.338

Traveling time (single trip) (min)

 ≤ 30

131

17

0.30 (0.16, 0.55)*

0.48 (0.11, 2.11)

0.330

 > 30

110

48

1

1

 

Cost of traveling (single trip) (n = 222) (Ethiopian Birr)

 ≤ 10 Birr

97

17

0.40 (0.21, 0.77)*

1.14 (0.25, 5.24)

0.866

 > 10 Birr

75

33

1

1

 

Patients category

 New

190

45

1

1

 

 Treatment failure

18

7

1.64 (0.63, 4.17)

0.52 (0.05, 5.12)

0.58

 Relapse

24

5

0.88 (0.32, 2.43)

0.94 (0.19, 4.75)

0.94

 Return after default

9

8

3.75 (1.37, 10.27)*

0.88 (0.05, 14.39)

0.93

Treatment phase

 Intensive phase

183

35

1

1

0.030

 Continuation phase

58

30

2.70 (1.53, 4.78)*

2.27 (1.5, 5.94)

 

HIV status

 Seronegative

153

52

2.30 (1.19, 4.46)*

1.97 (0.41, 9.39)

0.651

 Seropositive

88

13

1

1

 

TB status disclosure to the family

 Yes

192

45

1

1

 

 No

49

20

1.74 (0.94, 3.22)

1.47 (0.31, 6.90)

0.626

Number of comorbidity?

 > 1

89

49

5.23 (2.81, 9.74)

6.22 (2.21, 17.48)**

0.001

 No or 1

152

16

1

1

 

Knowledge

 Good knowledge

156

20

1

1

0.004

 Poor knowledge

85

45

4.13 (2.29, 7.44)*

4.11 (1.57, 10.75)**

 

Patient-provider relationship

 Good patient-provider relationship

183

32

1

1

0.004

 Poor patient-provider relationship

58

33

3.25 (1.84, 5.75)*

4.60 (1.63, 12.97)**

Alcohol intake

 Yes

35

23

3.22 (1.73, 6.00)*

5.03 (1.54, 16.40)**

0.007

 No

206

42

1

1

*Variables those were significant during univariate logistic analysis at P value 0.05

**Variables that were found to have significant association during multivariate analysis at P-value < 0.05

Discussion

In this study, the rate of non-adherence to antiretroviral therapy was found 21 point two percent This is in-line with studies done at Arba Minch governmental health institutions [9], Dawouro-zone public healthcare facilities [10], and Mbarara Hospital, Uganda [17] which reported 24.7%, 24.5% and 25%, respectively.

However, it is higher than studies done in North Gondar Zone- Northwest Ethiopia (10% and 13.6%) [16], Khartoum state, Sudan (14%) [18], State of Parana (8.5% %) [19], Kosovo (14.5%) [6], and Thailand (15.6%) [8]. This difference might be due to differences in socio-demographic characteristic, sample size, study designs, settings and time difference.

This finding is lower than studies conducted in Mekele, Ethiopia (55.8%) [20], E ward of Mumbai Municipal Corporation, India (50%) [7], Schenzhen, China (33.74%) [21]. The variation might be due to differences in study settings, study design, and socio-demographic characteristics. Study participants in Mekele were TB/HIV co-infected and those TB patients attending in hospital were included. The study in E ward of Mumbai Municipal Corporation was prospective cohort study and in Schenzhen, China all health facilities with TB treatment service were included.

In the current study participants in the continuation phase of treatment had significant association with non-adherence. Possible justification could be patients in continuation phase might have improved sign and symptoms of disease and expected as they are cured, thus they might be careless in taking medications. This finding is supported by studies in North Gondar Zone-Northwest Ethiopia, Kassala state, Sudan [22], Mbarara Hospital-Uganda. Number of co-morbidity had significant association with outcome variable. Participants who had more than one co-morbidities were had poor adherence to anti-TB therapy, like similar study reported in North Gondar Zone-Northwest Ethiopia, uMgmgundlovu health district.

Poor knowledge about tuberculosis and anti-TB therapy had significant association with non-adherence. This is similar to the results of studies in Dawouro-zone public healthcare facilities, E ward of Mumbai Municipal Corporation-India, Schenzhen-China. Poor patient-provider relationship also had significant association. This agreed to findings of studies in Sodo woreda, Southern Ethiopia [23]. Besides, alcohol intake had significant association with non-adherence. This is similar to the State of Parana, Mbarara, and Baringo, Kenya [24].

Forgetting, Being busy with other work, and being out of home/town were the major reasons for most participants for interruption of taking anti-TB medications. Different studies in North Gondar Zone, Alamata District, Mekele, and Baringo-Kenya, revealed as forgetting was the major reason for medication taking interruption/non-adherence. Being out of home/town was supported by studies in North Gondar Zone and Alamata District.

The finding of this study gives evidence based information for Federal Minister of Health of Ethiopia, regional health office, zonal and district health offices and other stake holders and the information will be used to design TB reduction strategies and take action to further decrease the level of drug non-adherence on anti-TB treatments and improve the outcome of TB treatments.

Conclusion

This study revealed relatively high non-adherence rate of tuberculosis treatment. To decline the TB treatment non-adherence and to improve treatment outcome of TB-patients; health professionals, health programmers and other stakeholders should give emphasis to prevention of co-morbidities, improving knowledge through health education, providing strong counseling about drug adherence with more emphasis on continuation phase of treatment and about disadvantage of alcohol intake, and strengthening of patient-provider relationship.

Limitations

Non-adherence was assessed according to data actually taken during the previous 1 month. So, participants might be subjected to recall bias. Patients attending the Hospital and health Posts were not included. This might impose limitation on generalization of findings to all TB patients in the town. In addition, this study did not assess the frequency of missed medications.

Abbreviations

AOR: 

adjusted odds ratio

CI: 

confidence interval

COR: 

crude odds ratio

DOTs: 

directly observed therapies

HIV: 

human immune deficiency virus

SD: 

standard deviation

SPSS: 

statistical package for social sciences

TB: 

tuberculosis

WHO: 

World Health Organization

Declarations

Authors’ contributions

HSM wrote the proposal, participated in data collection, analyzed the data and drafted the manuscript. AWA approved the proposal with revisions, participated in data collection, data analysis and revised subsequent drafts of the manuscript. Both authors read and approved the final manuscript.

Acknowledgements

Authors would like to express our gratitude to the University of Gondar College of Medicine and Health Science School of Nursing Research and Ethical Review committee for the approval of the ethical clearance. The authors would like to thank data collectors and supervisors for their commitment and the study participants for their valuable information.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The raw data would not be provided for the reason of protecting patients’ confidentiality. But, the summary data are available in the main document.

Consent to publish

Not applicable.

Ethics approval and consent to participate

The study was approved by University of Gondar College of Medicine and Health Sciences School of nursing Research and Ethical Review Committee with the Reference Number C/N/035/09/09. A permission and supportive letter were obtained from the head of each health centers. Each study participant was informed about the purpose, method, expected benefit, and risk of the study. They were also informed about their full right not to participate or withdraw from the study at any time, and deciding not to participate had no impact on their services. Written informed consent was obtained from study participants and anonymity was employed to maintained confidentiality.

Funding

The authors received no specific funding for this work.

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Authors’ Affiliations

(1)
Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

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