Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting

Abstract

Context Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. Objectives To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. Design, Setting, and Patients A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear-positive pulmonary TB were randomly assigned to the intervention or control group. Intervention The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. Main Outcome Measure Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. Results A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n=43) compared with 16.8% (n=125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). Conclusion The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries.

Household members and health care workers as supervisors of tuberculosis treatment

“…Our results confirm earlier studies from other program settings showing that household members are good DOT supervisors and can increase adherence and cure rates. 1,10,12,18 Household members appear to be better treatment supervisors than HCW in some program settings since they may more effectively mobilize a network of family support around the patient's treatment than HCW can. The involvement of other household members may be decisive for treatment completion and cure.…”

Promoting adherence to treatment for tuberculosis: the importance of direct observation

“…A recent report from Senegal 17 is an example of this. This wellcontrolled study reported a 12% higher cure rate among patients allowed to select their own "direct-observation-oftreatment supporter", but also featured intensive and sustained professional supervision and training and monitoring of the supporter at every level of the study.…”

“…In the Senegal study, 17 direct observation of treatment was delivered by a person selected by the patient. Self-administration was not an option.…”

Outcome of Tuberculosis Control Program in Red Sea State, Sudan

“…The retrieval system (phone, letters, home visit, etc.) can bring some patient to the hospital, but it would not be possible to guarantee that they take the prescribed drugs [18,19]. Other method like fixeddose combination may not prevent defaults.…”