An Introduction to TB treatment adherence
TB is noted as the leading cause of death in South Africa. While people living with HIV accounted for 63% of incident TB cases in 2015, TB is also recognised as being driven by poverty, poor nutrition, suboptimal living conditions, overcrowding, late presentation to health facilities, concurrent medical conditions, and low treatment success rates. The effort put into the screening and detection of TB cases in South Africa has increased the number of people on treatment; however, treatment failure remains a problem.
The three main causes of TB treatment failure are identified as the prescription of incorrect regimes, irregular or poor-quality drug supply, and poor patient adherence to treatment.
Adherence is the extent to which the patient acts in accordance with the prescribed interval and dose of treatment through treatment initiation (when the first dose of medication is taken), implementation (the extent to which the patient follows the treatment regimen), and discontinuation (when the patient reaches the end of the prescribed treatment and stops taking the medication).
The term treatment adherence suggests that the patient has a choice to follow the health care worker’s recommendations or not to, and is, therefore, an active partner in their own treatment.
POOR TREATMENT ADHERENCE
In South Africa, poor TB treatment adherence is linked to drug resistance, worsening medical conditions, prolonged infectiousness, unnecessary health complications, and increased rates of morbidity and mortality. Low treatment adherence also results in increased health care costs for both the health care system and for patients, with increased hospitalisation and expensive diagnostic tests being required.
Indicators of poor treatment adherence include:
- The patient’s failure to pick up or renew prescriptions;
- Failure to take medicine at the prescribed dosage level or at the prescribed interval; and
- Failed persistence or the abandonment of a treatment regimen.
Research suggests that there is no personality type or demographic type that makes a person more or less likely to adhere to treatment. The best way to understand how to overcome poor treatment adherence is to explore what gives rise to this phenomenon for the individual patient. This involves understanding both the intentional and non-intentional factors that result in non-adherence.
Ways to improve treatment adherence have been developed and tested in different countries for a variety of conditions.
A noticeable improvement in treatment adherence has been attributed to the following changes:
- Simplified drug regimens for patients, with a reduced pill burden;
- Appropriate patient education about the disease, the treatment, and how it works;
- Improved case management with patient education about side-effects, regular monitoring, and regular reviews of clinical reports to check on patient outcomes;
- Adequate counselling on discharge from hospital; and
- Pharmaceutical counselling, including an assessment of the patient’s knowledge about their condition and treatment, education on adherence strategies, and suggestions for lifestyle changes.
Treatment literacy is one of the keys to improving adherence. Treatment literacy involves the translation of complex medical information into a simpler language and format that ordinary people can understand. Treatment literacy means that individual patients, as well as the people around them in their communities, understand what TB treatment is and why it is important.
Where a patient and their health care worker are able to discuss the importance of adherence and to negotiate how treatment is taken, and how and when follow-up tests and visits happen, it is more likely that the patient will find ways to adhere to the treatment plan.
Interventions to increase adherence are categorised below into those that include the individual patient, interventions including the patient’s social network, interventions at the community level, and interventions within broader society.
Improving adherence at the individual level involves:
- Improving provider-patient interaction and communication addressing the patient’s perceptions of the seriousness of the disease, their understanding of the perceived benefits of treatment, and their selfefficacy;
- Engaging with views on health and wellness that might be outside the Western biomedical paradigm;
- Addressing personally perceived barriers to taking treatment and minimising costs and discomfort related to clinic visits;
- Improving cues to action, such as reminders to take treatment, appointment reminder systems, and late patient tracers;
- Increasing participation by the patient in decisions about their treatment plan and support;
- Providing more information about the effects of medication to reduce the risk of patients becoming nonadherent when experiencing treatment side-effects; and
- Developing a system of incentives and enablers for the patient, including written or verbal agreements for the patient to return for appointments or to collect treatment.
Interventions at the level of the patient’s social network include:
- Promoting disclosure to trusted and close family and friends;
- Promoting increased patient support from family, peers, and social networks; and
- Enhancing Directly Observed Therapy Short-Course (DOTS) programmes and training family members in to support patients.
Interventions at the community level include:
- Providing more information about TB and its treatment to communities; and
- Enhancing DOTS programmes and training community based treatment supporters, health workers, and support groups.
Interventions at the societal level include:
- Increasing the visibility of programmes in schools, workplaces, and communities to increase knowledge and improve attitudes towards TB;
- Improving existing adherence-support services offered by multidisciplinary health teams;
- Ensuring more effective staff training, motivation, and supervision within the health system; and
- Tackling the complex structural barriers to improved health.