Journal of Infection and Public Health 10 (2017) 527–533

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Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Factors contributing to non-adherence with treatment among TB

patients in Sodo Woreda, Gurage Zone, Southern Ethiopia: A
qualitative study
Cherinet Gugssa Boru a , Tariku Shimels b,∗ , Arebu I. Bilal c
a
Kolfe Keranyo Sub-City Food, Medicine and Health Care Administration and Control Authority, Addis Ababa, Ethiopia
b
Ethiopian Federal Police Commission Health Service Directorate, Medical Logistics and Pharmaceutical Service Coordination, P.O. Box 21652, Addis Ababa,
Ethiopia
c
Departement of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Poor adherence by tuberculosis (TB) patients to their medication contributes not only to the worsening
Received 5 August 2016 of their TB situation but also paves a way for incidence of drug resistance. This study, hence, aims to
Received in revised form 8 November 2016 explore factors contributing for non-adherence of TB treatment among TB patients in Sodo Woreda,
Accepted 18 November 2016
Gurage Zone, Southern Ethiopia. A qualitative study, which included 22 in-depth interviews from four
health centers and seven health posts, was conducted from February 25 to April 27, 2014. Although the
Keywords:
drugs were given free of charge, many patients were unable to adhere to their treatment because of one or
In-depth interviews
a combination of the following factors; lack of adequate food, poor communication between healthcare
Non-adherence
Qualitative study
providers and patients, beliefs in traditional healing system, unavailability of the service in nearby health
Southern Ethiopia facilities, side-effect and pill burden of the drugs, stigma and discrimination. The patients take their anti-
Tuberculosis TB medications under difficult circumstances and experienced a wide range of interacting factors. This,
in turn, has resulted for non-adhered treatment taking behavior by many patients. Health professionals
and policy makers should be aware of such factors and initiate sustained educational campaigns directed
towards all parties in the study area to obtain a good success with TB treatment.
© 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background per 100,000 population [3,4]. Despite the extensive expansion of

Tuberculosis (TB) is a major public health challenge worldwide.
It is the second leading cause of death from infectious diseases next
only to human immune deficiency virus (HIV) [1]. Above 90% of the
global TB cases and deaths occur in the developing world where
also 75% of the cases are in the most economically productive age
group (15–54 years) [2].
Even though Ethiopia achieved 100% geographical and above
92% health facility directly observed treatment schedule (DOTS)
coverage, the country is ranked as 8th among the TB high burden
countries in the world with an estimated incidence of 258 TB cases
Abbreviations: AIDS, acquired immune deficiency syndrome; DOTS, directly
observed treatment schedule; HEWs, health extension workers; HIV, human
immune virus; HP, health post; TB, tuberculosis; WHO, World Health Organization.
∗ Corresponding author.
E-mail addresses: cherinetgugsa@gmail.com (C. Gugssa Boru),
tarphar2008@gmail.com, tarphar2000@yahoo.com (T. Shimels),
arebu.issa@aau.edu.et (A.I. Bilal).
DOTS service in the country, the program performance indicators
remain unsatisfactory [4]. For example the rate of default from TB
treatment ranges from 12 to 20%, which is also higher than the
World Health Organization (WHO) recommendation of less than
10% [5].
Poor adherence contributes to worsening of TB situation not
only by increasing incidence but also by initiating drug resistance.
Resistance to anti-TB drugs has become a serious obstacle in the
control of the disease. Patients’ poor adherence to anti-TB therapy,
with an estimate of as low as 40% in developing countries, remains
the principal cause of treatment failure globally [6]. The WHO rec-
ommends at least 85% cure rate of all diagnosed TB cases [7]. In
order to achieve this cure rate, adherence needs to be in the order
of 85–90% [8].
Evidences from a variety of literature show that there are many
factors affecting adherence to TB treatment. Lack of access to for-
mal health services, traditional beliefs leading to self-treatment,
loss of income, lack of social support, drug side effects, pill burden,
lack of food, stigma with lack of disclosure, and lack of adequate

http://dx.doi.org/10.1016/j.jiph.2016.11.018
1876-0341/© 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
528 C. Gugssa Boru et al. / Journal of Infection and Public Health 10 (2017) 527–533
communication with health professionals were some of the
documented factors [9–11]. Knowing factors contributing to non-
adherence to TB treatment helps policy makers, health care
providers, the community as well as patients to tackle the problem.
Few studies have used qualitative methods to explore about fac-
tors contributing towards non-adherence to treatment among TB
patients. This study, thus, aims to explore factors contributing for
non-adherence among TB patients in Sodo Woreda, Gurage Zone,
Southern Ethiopia.
Methods
Study design and period
We used a phenomenological study design approach to explore
factors contributing for non-adherence with TB treatment over a
two-month period from February 25 to April 27 of 2014.
Study area
The study was conducted in Sodo Woreda (second from low-
est administrative units in the government structure), one of the
districts from Gurage Zone, in Southern Nations, Nationalities and
Peoples Regional State of Ethiopia. The district is bordered, from
south, by Meskan and from west, north and east by the Oromia
regional state. The administrative center of Sodo is Buee and it cov-
ers an area of 109,943 ha. The district is about 178 km far from the
capital of the region, Awassa and 105 km from Addis Ababa. The
total population of the Woreda is estimated to be 175,725 of which
89,619 (51%) are female according to the 2007 national census pro-
jected for 2012/2013. Ninety percent of the population resides in
the rural part of the district [12].
Majority (93%) of the inhabitants practice orthodox Christianity
faith. The Woreda is primarily inhabited by the Sodo Gurage and
small number of Oromo and Amhara ethnic groups. There are 4
urban and 54 rural kebeles (lowest administrative units in the gov-
ernment structure) under the district. The rural part of the district
includes both highland and lowland kebeles which have difference
in morbidity rates. At the time of the survey, the district had eight
health centers, 55 health posts as well as two private clinics and
three drug stores [12].
Selection of study sites and participants
Among the seven health centers and 16 health posts that serve
DOTS program in the Woreda, four health centers (eleven partici-
pants) and seven health posts (eleven participants) were selected.
The research sites were chosen based on advice from Woreda focal
personnel, Woreda administrator, Woreda health office, health
extension workers (HEWs) and DOTs clinic nurses whereas the sites
were considered to be DOT clinics, they were also chosen because
they represented diversity being located in different areas of the
Woreda. Upon selecting the study participants, criterion purposive
sampling was employed. Consideration was given to priority cri-
teria to meet the research objectives. The parties consulted during
the study site selection were also asked to assist on the recruit-
ing process of potential interviewees. Health center databases and
clinic DOTS registry books were used in tracing the participants on
any phase of treatment.
The study included those TB patients who had interrupted TB
treatment or who had poor adherence to their treatment. The
health facility TB registration book was used as a source of infor-
mation about the patient characteristics. A total of 22 respondents
were involved for the interview; five in Buee health center, two in
Kela health center, two in Tiya health center, two in Refanso health
center, three in Wacho health post, two in Gogeti-one health post,
two in Agamsenado health post, one in Gogeti-three health post,
one in Wodoget health post, one in Gogeti-two health post, and
one in Adazer health post. Out of the 22 participants, 18 were new-
patients initiated for an intensive phase, two were relapsed and
were under a continuation phase and the rest two were failure who
are on their ‘intensive phase’ treatment.
Confirmation of participants’ involvement into the study was
based on their consent and as per the recruitment guideline devel-
oped by the researchers. The guideline contains procedures briefly
about the potential participant. After taking the address of recruited
participants, the investigators and HEWs visited their home. Par-
ticipants had to fully understand what the study was and how their
privacy will remain confidential. The voluntary nature of the study
was explained to the study participants. If the patient wishes to
take part, they were given to sign the consent form. Last, the inves-
tigators discussed with the selected participants to arrange and fix
the time and date for the interview.
The major variables of interest were; reasons for non-adherence
against TB treatment from lived experiences and the views
of TB patients on the disease and its treatment. Probes were
directed based on subsequent narrations. Each session lasted about
60–90 min for the in-depth interviews. Data was collected by two
research assistants who had a prior experience on qualitative data
collection and could speak both Amharic as well as Guragigna lan-
guages. They were trained for one week on TB and skills required
in respective responsibilities.
After obtaining consent from participants, in-depth interviews
were tape-recorded. Notes were also being taken during the inter-
views. The research assistants were engaged with participants by
posing question in natural manner, listening participants response
attentively and asking follow-up questions and probes based on the
participants responses. The interview was conducted face-to-face
and one interviewer and one participant. The interview was con-
ducted in a convenient place for the participants. These interviews
were taking place in the patient’s own home and at health facility
based on their interest and residence.
Operational definition
Non-adherence
A patient is said to be non-adherent if he/she missed three or
more of the doses of the prescribed anti-TB drugs.
Ethical approval and consent to participate
Prior to gaining consent form the participants, permission to
carry out the study was requested and obtained from Jimma
University Research Ethics Committee. Necessary permission was
obtained from the respective localities of Sodo Woreda adminis-
trative council, the Woreda health office and the health centers.
After all permission requests were granted, an invitation letter, that
explains the purpose of the study and rights of participants, was
distributed to all participants. Participants were assured that they
could withdraw from the study at any time during study period.
Written consent was sought in all cases. The privacy of subjects
was fully respected during data collection and dissemination of
results. Sessions were arranged in a private and quiet place conve-
nient for the participants. The identities of in-depth interviewees
were changed to ensure that they would not be identified. The
tape records and transcripts were kept in a safe place and remain
confidential.
Analysis
Data collection and analysis were done simultaneously. After
each interview data collection, the investigators and the research
 C. Gugssa Boru et al. / Journal of Infection and Public Health 10 (2017) 527–533
Table 1
Characteristics of the study population in Sodo Woreda, Gurage Zone, Southern
Nations, Nationalities and Peoples Region, Ethiopia, 2014.
Characteristic N tional healing system, feeling of wellness, nature of the job, lack of
Gender
Female 14
Male 8 to be taken under a direct observation by a health care provider. As
Total 22
Age distribution
18–20 3
20–39 12
40–60 7
Total 22
Category of patient
New patients 18
Re-treatment 4 who faced such challenges preferred to interrupt treatment despite
Total 22
assistants listened to the tape recorded interview and thoroughly
discussed and clarified the contents. They took notes while listen-
ing, capturing the main essence of the answers provided by each of
the participants.
All notes and the recorded audio were transcribed and trans-
lated from local language (Amharic and Guragegna) into English
and used to complete the hand written notes. The write-ups were
produced and time was taken to prepare a contact summary, which
involved reviewing the main concepts, themes, issues and ques-
tions seen during the contact. This guided planning for the next
contact, gave a chance for modification in the approach and to
decide on continuing the data collection until a point of theoret-
ical saturation. Each transcript has been given a proper identifying
label.
The investigators and research assistants transcribed and trans-
lated, close to verbatim, of each interview after having discussed
and agreed on its content. Following the transcription, a line-byline
coding of the data was done.
Each interview’s content was mapped and categorized from its
text concept using open coding approach. First, starting from the
early coding of the data, 147 codes were developed. Then, by read-
ing the data and using thematic coding, it was merged to 9 family
codes and those family codes were merged to 4 main themes. Those
merged codes were aggregated while the concepts were defined
and elaborated. An inductive approach was followed to allow clus-
tering of ideas and patterns to emerge. The codes were collapsed
into categories of central themes. Following the development of
central themes of the study, the researchers rearranged transcripts
and wrote a rich and complete description of the lived experiences
from which the essential structure of the phenomena was formu-
lated. To manage the overall coding developing process ATLAS.ti-7
software was used.
Results
Participants and content themes
A total of twenty-two participants were successfully inter-
viewed, of which 14 were female and eight were male. The mean
age of the participants was 36 years (range 15–60 years old) and 18
of the patients were new to anti-TB treatment. Most of the study
participants were rural dwellers (Table 1).
In this study, one main theme and four sub-themes were devel-
oped from the content analysis. The main theme was; factors
contributing for non-adherence to tuberculosis treatment and the
four sub-themes were; (1) client related, (2) health service related,
(3) medication related factors and (4) social influence.
529
Client related factors
Client related factors encompass economic factors, use of tradi-
family as well as community support.
The intensive phase of TB treatment for all patients is required
a result, patients who came from distant areas were subjected to
rent houses in the towns where TB treatment centers were located.
In addition, it was also mentioned that money plays a crucial role
in transportation, registration and diagnosis at the health facilities,
expense for food, and to meet other basic needs.
Majority (seventeen), of the TB patients confirmed that lack of
money was the main reason for treatment non-adherence. Patients
their desire to continue. To a question posed about the financial
challenges they faced:
A TB patient who was absent from collecting her drugs has nar-
rated as follows:
“. . .Yes, if I had the money, I would already have gone back
to the health center. What can you do? Many things demand
money. . .”(34 years old female participant, Wacho health post).
Similarly, another TB patient said:
“Many patients from rural areas do not come to the health facility
on time for treatment. I went to the health facility when I am seri-
ously sick. This is mainly because of lack of money for transportation
as the distance is far away from the health center.”
(35 years old female participant, Tiya health center).
Nine of the respondents also emphasized that they had expe-
rienced food shortage during treatment and that food played a
pivotal role in complementing TB treatment. They mentioned that
when there was food shortage, they failed to comply with medica-
tions. The patients believed that lack of food or inadequate food was
associated with more severe side effects and a difficulty to tolerate
the drugs. For many of them, the amount and quality of food needed
must be proportional to the possible side effects of the drugs taken.
They pointed out that drugs could be harmful on an empty stomach,
and that it was better not to take drugs if one had not eaten.
A TB patient who poorly adhered to his medication stated:
“It has been very hard for me to take treatment because I don’t have
anything to eat.”
(60 years old male participant, Refenso health center).
Belief in traditional healing for curing TB was associated with
non-adherence to TB treatment. Twelve of the TB patients reported
about their use of traditional healing systems before starting
anti-TB medications, during treatments as well as if their health
condition did not improve. They described that traditional healing
system was effective, took shorter treatment period, supportive,
keeps the patient away from bad spirits and obtained at affordable
price.
The patients also reported that they preferred traditional heal-
ing systems because they are more accessible than the health
facilities. One poorly adhered TB patient reported her use of a tra-
ditional healing system as follows:
“I tried local herbs and religious remedies in many occasions. . .
And I did not continue the treatment until my situation become
worsened and reached to a point that I could not milk cow for my
children”.
(38 years old female participant, Gogeti-one health post).
Another patient says:
530 C. Gugssa Boru et al. / Journal of Infection and Public Health 10 (2017) 527–533
“I felt better soon after the treatment. . . But, in the meantime, I
became very sick. When my condition worsened, my family brought
me to a special man, who was known in the area for his best healing
skills as a traditional healer. . .. he boiled some herbs for me to
drink. . .. It did not really help, but I continued to use it with the
hope that I would get better. I noticed that since I had started using
the medication from the health center, my health improved a lot.”
(49 years old male participant, Wacho health post).
Quite a number of participants (eleven) reported that they
stopped taking their anti-TB drugs either when their TB symptoms
disappear or when they felt well. Patients who felt well assume
that they are cured from the disease. In this study, patients do not
acknowledge the dangers of not completing TB treatment mainly
because of subsiding TB symptoms or feeling of wellness. The fol-
lowing was verbalized by one non-adherent TB patient:
“I stopped taking medicines because I felt well already.”
(31 years old female participant, Wacho health post). The other
interviewee client adds:
“I stopped taking the treatment drugs because I feel okay after one
month of treatment.”
(25 years old male participant, Tiya health center).
Eight of the TB patients have had discontinued their treatment
because of lack of family and community support. The patients
revealed that care and support are immensely important for a TB
patient’s adherence to treatment especially during the intensive
phase. How family support could influence treatment adherence
was narrated as follows: “I did not have any positive experience from
my family. . . no one is helping me. . . in fact, my families live in the
countryside, but. . .. I am a student and live in the town, sometimes
even I become hopeless during the times I miss my drug.”
(18 years old female participant, Buee health center).
Likely, another TB patient said: “This is where I have found a real
help when I stopped taking drugs because of no support from any of
my family members. . .”
(33 years old female participant, Adhazer health post).
Ten of the TB patients in the study area were found to be non-
adherent to their anti-TB medication due to the nature of their
work. In addition, there are patients who reported losing their job
after their TB diagnosis was known, or because they were too ill to
continue working.
One non-adherent TB patient has explained his experience:
“I was the only one working in our family, so I could not go every
morning to my follow up clinic . . .”
(33 years old male participant, Adazer health post).
In the same way another TB patient said: “. . .it is hardly possible
to adhere with therapy because if you are working, you will forget
about your medications. You become busy and the nature of our work
is heavy. Good if you have a light job and you just sit. You still have time
to think about your medicines. But with me, I am just a day laborer. . .
it’s difficult and will really affect taking of medicines.”
(31 years old female participant, Wacho health post).
Health service related factors
Patient-provider relationship, working hours of health facilities
and distance were considered as the health service related theme.
Poor client-provider interaction was found to be one of the rea-
sons for poor adherence. One participant responded it as follows:
“As I have not understood that I had to go back to the clinic and refill
my medication until six months, I discontinued the drugs myself
after having taken only for one month. . ..”
(45 years old female participant, Agamsenado health post).
The study also revealed that friendly relationship between
healthcare workers and patients was an important contributor for
good treatment adherence. Fourteen of the interviewed TB patients
had positive feedback on the health care staff. On the other hand,
eight of the non-adhered patients had experienced poor commu-
nication with the health center and HP staff.
To a question raised on what patient-provider relationship was
looking like in their follow up clinics, and how it affected their
adherence, a patient has said the following;
“My experience at this Clinic is not good, because, I found that the
nurses are not punctual at their job. . . Especially Sister (name) is
not present in the office the time you want her. I am not motivated
to go to the clinic. I have complaints.”
(33 years old male participant, Adhazer health post).
The study participants have also raised concerns on working
time of the health facilities, mentioning that it was one of the com-
mon reasons contributed for their poor adherence to their anti-TB
treatment.
Five of the respondents would prefer the clinics to have flexible
working hours. Here is an opinion of one non-adherent TB patient
regarding health facility work hours’ impact on their treatment
adherence:
“The opening time of the health center is not appropriate for me.
Because, I am a student . . .and I miss morning classes to attend
there. As a result of this, I did not like the first 2 month treatment
program.”
(18 years old male participant, Buee health center).
The other non-adherent TB patient states on the same issue:
“. . .additional problem I can mention you was that time of drug
collection was not appropriate for me because my husband died
just before one year. I had work load and I was unable to collect the
drugs on time.”
(21 years old female participant, Buee health center).
Accessibility of health institutions were also the other main
cause for poor adherence during TB treatment.
The effect of distance on TB treatment adherence was narrated
as:
“The distance is so far, I was unable to go and back day to day
specially in the first two months because it took me over half an
hour to go on bare foot and· · ·Many people say about 40 minutes
to get to the health center.”
(18 years old female participant, Buee health center).
A 49 years-old male non-adherent patient also remarked: “I am
a man and I had a hard time to reach here. You can imagine how
difficult it could be to bring children and women from remote kebeles.
When they get TB, we treat them with traditional medicine. Sometimes
they are cured or they may live with the disease for a long period. . .
in some cases they die. That is all we can do . . ..” (49 years old male
participant, Woduget health post).
Medication related factors
Medication related factors were among the causes of poor
adherence to TB treatment. In this respect, side-effect of drugs,
 C. Gugssa Boru et al. / Journal of Infection and Public Health 10 (2017) 527–533
pill burden and size of the tablet were enumerated as contributing
factors for non-adherence to anti-TB medications.
Side effects were mentioned as one of the factors for non-
adherence by eleven participants, mainly at the beginning of
anti-TB treatment or upon initiation of concomitant treatment. The
common side-effects revealed by the participants included; body
pain, vomiting, feeling weak, discoloration of urine and lack of
appetite.
One of the TB patients explains: “The side effect of the drugs was
so dangerous that makes me always feel tired and vomit. . . Because
of this reason, I discontinued the drug and started ‘Tsebel’ that is holly
water.”
(30 years old female participant, Refanso health center).
Another participant who discontinued his ant-TB medication
after experiencing severe side effects presents:
“My urine turned red; I thought it was blood caused by the medi-
cation. I thought it was safer to stop the medication.”
(25 years old male participant, Tiya health center).
Five of the TB patients in this study had a problem with the
tablets. They found the tablets to be either too big or too many.
One TB patient who had had typhoid fever witnessed as:
“I missed my TB drugs when I was taking medicines for typhoid
fever too. This was because, my mother told me not to take all the
drugs at once as this may affect my health.” (33 years old male
participant, Adhazer health post).
Social influence associated to TB
The existing socio-cultural barriers and taboos associated with
TB have also been found to be factors contributing for poor adher-
ence in the study area. Due to the perceived presence of stigma in
the community, patients do not disclose their disease state to their
friends and community members.
In the rural part of the study area, TB patients were not secret
about their disease. The patients initially told only their family and
neighbors about their disease, but after a while more and more
neighbors found out about their ‘lung disease’. Sometimes, the
whole neighbors knew that the patient had a ‘lung disease’. The
neighbors and family members were often involved in encourag-
ing and helping the patients with their treatment as interviewed
patients witnessed. This is evidenced by one of the participants:
“Rural people do not know about TB. . .. I can tell you that they did
not feel anything about my disease.”
(38 years old female participant, Gogeti −three health post).
In the urban areas, however, four of the patients hide their
disease. It was found that patients’ beliefs were a major cause of
self-discrimination. As mentioned by the participants, they isolated
themselves from family and friends, and particularly from children,
because of fear of transmitting the disease, avoiding gossip and
potential discrimination.
Herewith is a narration by one patient:
“In the beginning, my neighbors did not talk to me so much any-
more, but after a while, they become a bit normal and lately good
as it used to be.”
(15 years old male participant, Buee health center).
Other non-compliant TB patient said: “I arrive early in the morning
so that people could not see me. I used to conceal my illness from
people.”
(42 years old female participant, Kela health center).
531
Discussion
Even though, TB treatment and diagnosis in Ethiopia are pro-
vided free of charge with the aim of decreasing the financial burden
for patients [13], results from our study indicated that economic
factors still play an important role for poor adherence. Similar find-
ings were also reported elsewhere in the country [9–11,14]. The
main aspects of financial burdens, as substantiated by many of the
participants included; costs of transportation, house rent for those
who came from rural area, and medical examinations. Non adher-
ence was also aggravated by the lack of food security whilst taking
anti-TB medications. This is in line with other qualitative studies
conducted inside the country [9–11,15].
Inaccessibility of health services, especially for those who came
from remote areas, was reported to have profound effects on
adherence to TB treatment. This is the most prominent factor in
developing countries where there is a limited physical accessibility
to such services and poor infrastructure [9–11,14,16,17]. Despite
the availability of eight health centers and 54 health posts in the
present study area, there were only seven health centers and six-
teen health posts which provide health services like DOTS to a
population of over 175,725 [12]. Majority of the people in these
settings lived in areas which required more than one hour travel
on bare foot for reaching a health facility. Furthermore, the working
hours of the health centers and health posts have their own contri-
bution for non-adherence, particularly, for those patients who have
job since the working hours are similar. Patients are forced to miss
either their job or the pills especially during the intensive phases.
For these kinds of study area, a community-based DOTS was doc-
umented to have key impact for improving accessibility to clients
[18].
More than half of the clients in this study resorted to traditional
healing system during or after their TB medication, for their bod-
ily discomfort as well as in the intention to mask the side effect
arising from anti-TB drugs. As implied by the participants, even
though their treatment resort is caused, to a large extent, by cultural
beliefs, the family members, as well as accessibility of the services
had a role in the reported behaviors’ of the TB patients. Similar
findings were reported in Ethiopia as well as abroad [10,19]. Other
factors reported to contribute for poor adherence in the study area
were; feeling of wellness after taking some of the doses and side
effects of the drugs which often happen during the intensive phase
of treatment. Patients did not conceive the need to adhere with the
continuation phase, hence, failing to complete full course of treat-
ment. This is supported by similar findings in the literature [19–23].
Additionally, the pill burden for patients who take drugs other than
anti-TB medications as well as the size of the tablets were men-
tioned as impeding factors for treatment adherence. Coupled with
this, poor interpersonal communication between the patients and
their healthcare providers has also brought about a gap in address-
ing clear and accurate information about the treatment. This may
enforce patients not to express their concerns to the providers.
Findings suggest that counseling plays an immense role in treat-
ment adherences [9]. Patients should be well informed about the
side effects, pill burden as well as beliefs related to amount and
quality of food that need to be consumed.
In this study the level of stigma seems to have a different pat-
tern. In the rural part of the study area, TB patients were not
subjected to stigma and discrimination although patients always
referred to their disease as ‘Yesanba Beshita’ or ‘yanget-biret’ or
‘yanget-firafira’ in local terms instead of tuberculosis. This is mainly
because, they considered the disease is not severe and it comes
from God. But, in the urban areas, some patients did hide their con-
dition, although they would normally inform their family. Similar
findings were also reported that patients isolated themselves from
532 C. Gugssa Boru et al. / Journal of Infection and Public Health 10 (2017) 527–533
their family, the society and their friends due to the stigma they
fear [24].
Family and community support is identified as an important
factor for influencing treatment adherence. They are crucial for
adherence to anti-TB treatment not only by providing money for
food and transportation but also by providing encouragement,
motivation, as well as reminding their medication, assisting with
the administration of medications and comfort for those patients
who had lost hope. Similar findings are reported in Ethiopia [25,26].
As well as in other studies conducted in Pakistan [27], Gambia [28],
Nepal [29], Canada [30] and South Florida [31] which reported that
the role of family is immensely important, especially, in financial
assistance, collecting medications and emotional support.
This study is based on interviews with a total of 22 TB patients.
It lacks the view of patients who successfully completed treatment
and healthcare providers working in the DOTS facilities. However,
the study took place in an urban as well as rural setting so that
the results would reflect diversity in views and experiences. We,
thus, believe that our study can provide valuable insights into the
experiences of TB medication.
Conclusion
The patients take their TB medication under difficult circum-
stances and experience a wide range of interacting factors which
impact their treatment taking behavior. Lack of adequate food, poor
communication between healthcare providers and patients, beliefs
in traditional healing system, unavailability of the DOTS service in
nearby health facilities, side-effect and pill burden of the drugs,
stigma and discrimination were factors that contributed to poor TB
treatment adherence in the study area.
Health professionals and policy makers should be aware of such
factors and initiate sustained health education campaigns directed
towards patients, health care providers, patients’ close contacts,
traditional health practitioners, religious leaders and the commu-
nity at each visit using local language. The programs should be
comprehensive to include about; the nature of the disease, dura-
tion of treatment, possible side effects and how to deal with them
and consequences of not completing TB treatment. The Directly
Observed Treatment Schedule (DOTS) should be decentralized in all
peripheral health facilities, including health posts, to make progress
towards achieving success on TB control program.
Consent for publication
Not applicable.
Availability of data
The datasets analyzed during the current study are available
from the corresponding author.
Authors’ contributions
CG conceived the idea and designed the study. CG and AI coor-
dinated the data collection, performed data entry and analysis. CG,
AI and TS were involved in the write up process. All authors have
read and approved the final manuscript.
Funding
No funding sources.
Competing interests
None declared.
Ethical approval
Prior to gaining consent from the participants, permission to
carry out the study was requested and obtained from Jimma
University Research Ethics Committee. Necessary permission was
obtained from the respective localities of Sodo Woreda adminis-
trative council, the Woreda health office and the health centers.
After all permission requests were granted, an invitation letter,
that explains the purpose of the study and rights of participants,
was distributed to all participants. Participants were assured that
they could withdraw from the study at any time during the study
period. Written consent was sought in all cases. The privacy of sub-
jects was fully respected during data collection and dissemination
of results. Sessions were arranged in a private and quiet place con-
venient for the participants. The identities of in-depth interviewees
were changed to ensure that they would not be identified. The
tape records and transcripts were kept in a safe place and remain
confidential.
Acknowledgements
Our appreciation goes to the patients who were involved in this
study. We would, also, like to thank the Woreda health office work-
ers, administrative officers and all health professionals for sharing
their valuable time as well as tremendous generosity and hospital-
ity.
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