INT J TUBERC LUNG DIS 6(4):307–312
© 2002 IUATLD
Factors affecting patient compliance with anti-tuberculosis
chemotherapy using the directly observed treatment,
short-course strategy (DOTS)
S. J. O’Boyle,* J. J. Power,* M. Y. Ibrahim,† J. P. Watson‡
* University of Leeds School of Medicine, Leeds, UK; † Unit of Infectious Diseases, Public Health Department, Sabah,
Borneo, Malaysia; ‡ Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds General
Infirmary, Leeds, UK
S E T T I N G : Kota Kinabalu and surrounding communities
in Sabah, Malaysia.
O B J E C T I V E S : To establish factors affecting compliance
of patients with anti-tuberculosis chemotherapy, their
knowledge of the disease, and views on improving the
DOTS strategy.
D E S I G N : Interviews with compliant patients attending
clinics for DOTS treatment and with non-compliant pa-
tients in their homes, in August and September 2000.
R E S U L T S : A total of 63 compliant and 23 non-compliant
patients were interviewed. For non-compliant patients,
reaching the treatment centre entailed greater cost (P 
0.005) and travel time (P  0.005) compared to compli-
ant patients. Cost of transport was the reason most fre-
quently given for non-attendance. Non-compliant pa-
tients were more likely to have completed secondary
TUBERCULOSIS is a significant cause of morbidity
and mortality on the island of Borneo. Statistics from
the Central Public Health Department in Kota Kina-
balu, the State Capital of Sabah, show that in 1999
there were 550 new reported cases, giving an incidence
of tuberculosis amongst the general population of 175
per 100 000 population.1 There were a total of 142
deaths due to tuberculosis in Sabah: 80% of those
affected were Malaysian and 20% were non-Malay-
sian, and most individuals were aged over 60 years.1
Tuberculosis in Malaysia is treated using a combi-
nation of four drugs, administered by directly observed
therapy at a clinic, in either daily or twice weekly treat-
ment regimens.2 At the time of this study there were 76
dispensaries and 134 rural health clinics, and there are
aims to increase this number.1 Patients are deemed to
be non-compliant when they have missed more than 7
consecutive days of treatment. If patients are identified
as non-compliant, a specialist defaulter tracing team
visits their home address to establish why they have
Correspondence to: John Watson, Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds Gen-
eral Infirmary, Great George Street, Leeds LS1 3EX, UK. Tel: (44) 0113 392 5296. Fax: (44) 0113 392 6316. e-mail:
john.watson@leedsth.nhs.uk
Article submitted 29 June 2001. Final version accepted 29 December 2001.
SUMMARY
education (P  0.05), and to be working (P  0.01).
More non-compliant patients had family members who
had had the disease (P  0.01). There was no difference
between the groups for overall tuberculosis knowledge
scores; however, non-compliant patients were more
likely to think that treatment could be stopped once they
were symptom free (P  0.01). Most patients (73%) felt
that the DOTS system could be improved by provision
of more information about tuberculosis.
C O N C L U S I O N : Compliance with DOTS in the Kota
Kinabalu area is affected by travel expenses, time spent
travelling to treatment centres, and having family mem-
bers who have had the disease. Patients would like more
information on tuberculosis.
K E Y W O R D S : tuberculosis; DOTS; South-East Asia;
compliance
not attended the clinic for treatment. If a patient is not
at home messages are left with friends or relatives. If
patients subsequently fail to attend they are revisited.2
Approximately 10% of patients become non-
compliant, and the retrieval rate for such patients is
59%.1 The aims of this study were to compare compli-
ant and non-compliant patients being treated for
tuberculosis in Kota Kinabalu, Sabah, Malaysian
Borneo, to determine factors that may influence com-
pliance, to establish reasons why non-compliant
patients were not attending health facilities, and to
seek patients’ views on how they thought the system
could be improved. This may allow improvements to
be made to the administration of the directly ob-
served treatment, short course (DOTS) strategy.
PATIENTS AND METHODS
A questionnaire was designed to assess the demo-
graphic details of the patients, the treatment and side
308 The International Journal of Tuberculosis and Lung Disease

effects of their disease, the costs to them of treatment,
their knowledge of tuberculosis and its treatment and
their views on how the DOTS system could be
improved. In Malaysia tuberculosis is diagnosed using
clinical, radiological and or bacteriological evidence.
Three sputum specimens are collected for direct
smears for acid-fast bacilli and for culture.
The questionnaire was used in two clinics between
10 August 2000 and 26 September 2000 in Kota Kin-
abalu. All patients were receiving treatment under
DOTS protocols, and all were interviewed by one of
the authors (SJO or JJP), in the health facilities where
they were receiving treatment, with the help of nurses
to translate the questions from English into Malay. All
patients with a diagnosis of sputum smear-positive pul-
monary tuberculosis attending for treatment during
this period (n  63) were asked for consent to be inter-
viewed; none refused. The patients were at various
stages in their treatment, and at the point of interview
all had been fully compliant, as assessed by an analysis
of their treatment records. The questionnaire was also
administered whilst on visits with the defaulter tracing
team during the same time period to the homes of non-
compliant patients (n  23). The same questions were
asked using the defaulter tracer team workers as trans-
lators. Patients classified themselves as native (Malay-
sian) or non-native in the questionnaire.
The patients’ knowledge of tuberculosis and its
treatment were assessed by six questions adapted
from a study by Liam et al.3 One point was awarded
for each correct answer, to a maximum score of six.
The question: “Should patients eat with their fami-
lies?” was included because family meals are cultur-
ally important, and unnecessary isolation may add to
the stigma of the disease.
All tuberculosis treatment is free to patients in
Sabah; however, as patients must pay their own travel
costs a level of expense is incurred. Another cost to
patients was the time taken to travel, wait for their
consultation and then return home from the clinic.
Patients were asked how long it took them to travel.
This was converted into an opportunity cost index for
the patient by multiplying the time taken for the
patient to travel to the centre by the total cost of
transport, using the formula: Cost of travel (Ringets) 
travel time (minutes)  opportunity cost of treatment
(at the time of writing $1 US  3.8 Malaysian
Ringet). Travel time and travel cost are likely to be
related, and multiplying may overestimate the cost
incurred by travel time. However, it was felt that this
provided the most realistic reflection of opportunity
cost of attending the clinic in this study.
Patients were given a list of suggested improve-
ments to DOTS from which they could pick more
than one or make suggestions of their own. The sug-
gestions given were mobile clinics, financial aid with
travel for the very poor, out of hours clinics, involve-
ment of family members in administration of the

Table 1 Details of patients’ sex, ethnic group, level of education and occupation

Compliant Non-complaint
patients patients
n (%) n (%) P value
Sex 0.1
Male 37 (58.0) 16 (69.6)
Female 26 (41.3) 7 (30.4)
Admitted to hospital for TB 0.1
Yes 29 14
No 34 9
Affected family members 0.01
Yes 21 14
No 42 9
Side effects with treatment 0.1
Yes 49 14
No 14 9
Symptoms today 0.1
Yes 35 14
No 28 9
Nationality 0.005
Native Malaysian 17 (27) 14 (60)
Non-native 46 (73) 9 (40)
Education
None 26 (41) 10 (43) 0.5
Up to primary school only 24 (38) 4 (17) 0.05
Completed secondary school 13 (21) 9 (40) 0.05
Occupation
Not working 39 (62) 2 (9) 0.01
White collar 5 (8) 7 (30) 0.01
Student* 1 (2) 11 (48) 0.01
Labourer 18 (29) 3 (13) 0.2

* A student is defined as anyone currently studying in primary, secondary or tertiary education.

 Factors affecting compliance with DOTS 309

Table 2 Patient income and costs involved with attending for
treatment. Values are expressed as mean (standard deviation)
Category Compliant Non-compliant
Income/month, US$ 103.28 (134.51) 99.08 (74.12)
Travel cost ,US$ 0.41 (0.30) 0.66 (0.26)
Travel time (mins) 20.58 (19.35) 44.56 (55.83)
Opportunity cost 45.18 (98.04) 170.26 (295.18)
treatment, and provision of more information on
tuberculosis.
Statistical analysis
The link between compliance status and native origin,
hospitalisation, sex, having family members who had
had the disease, age, occupation, education and the
presence of side effects, was assessed using Yates cor-
rected 2 tests. Differences between the compliant
and non-compliant groups with respect to income,
cost of travel to the centre, amount of time spent
travelling to the centre and the opportunity cost of
travelling to receive treatment were compared using
the Mann-Whitney test.
Logistic regression was used to identify which fac-
tors were independently associated with compliance
status. Calculations were performed using Excel ver-
sion 7.0 (Microsoft 1997) for t-tests and 2 tests and
SPSS version 10.1 (SPSS Inc, Chicago, IL) for regres-
sion and MannWhitney tests.
RESULTS
Demographic details
A total of 86 interviews were conducted in the study:
with 63 patients in the compliant group and 23
patients in the non-compliant group.
The mean (standard deviation) age of the entire
interviewed population was 34 (14.3) years. There
P value was no statistically significant difference between the
ages of the compliant (mean 34.9 [13.61] years) and
0.5
0.01 the non-compliant groups (mean 31.5 [16.12] years).
0.005 Table 1 shows details of patients’ ethnic group, their
0.005 level of education and occupation. The P values indi-
cated are for comparison between compliant and
non-compliant groups.
No statistically significant differences were found
between the groups for sex differences, past hospital-
isation, side effects, income, knowledge or age. A
higher proportion of non-compliant patients were
native Malaysian. Significant differences were found
between the groups for level of education. Non-
compliant patients were more likely to have com-
pleted secondary education (P  0.05). There were
also differences in occupations between the groups.
Non-compliant patients were more likely to be white
collar workers (P  0.01) and students (P  0.01).
Compliant patients were more likely to be not work-
ing (P  0.01).
The incomes, travel times, travel costs and oppor-
tunity cost index for the two groups are shown in
Table 2. There was a significant difference between the
cost index (opportunity cost) paid by non-compliant
and complaint patients (P  0.003). After adjusting
for this difference by logistical regression the differ-
ence between natives and non-natives was not signif-
icant (P  0.387). Therefore, cost and travel time
taken together as a representation of opportunity cost
are more important factors than nationality.
Because of the close correlation between travel cost
and travel time, it was not possible to determine which
of these may have a greater effect on compliance.

Table 3 Patients’ knowledge of tuberculosis

Compliant Non-compliant Total

n (%) n (%) n (%) P value
How is TB transmitted? NA
Droplets 36 (57.1)* 11 (47.8)* 47 (54.7)*
Eating utensils 23 (36.5)* 3 (13.0)* 26 (30.2)*
Don’t know 13 (20.6)* 11 (47.8)* 24 (27.9)*
Should you eat with family members? 0.05
Yes 32 (50.8) 16 (69.5) 48 (55.8)
No/unsure 31 (49.2) 7 (30.5) 38 (44.2)
Does your family need to be screened for TB? 0.05
Yes 51 (81.0) 17 (73.9) 68 (79.1)
No/unsure 12 (19) 6 (26.1) 18 (20.9)
Is TB curable with proper treatment? 0.2
Yes 59 (93.7) 19 (82.6) 78 (90.7)
No/unsure 4 (6.3) 4 (17.4) 8 (9.3)
Can TB be cured with 4 weeks treatment? 0.2
Yes/unsure 34 (54) 15 (65.2) 49 (57)
No 29 (46.0) 8 (34.8) 37 (43.0)
Can treatment be stopped once you are symptom free 0.01
even though the prescribed treatment duration
has not been reached?
Yes/unsure 16 (25.4) 13 (57.5) 19 (33.7)
No 47 (74.6) 10 (43.5) 57 (66.3)

* Respondents may have answered with more than one option.

310 The International Journal of Tuberculosis and Lung Disease
Table 4 Reasons for non-compliance with treatment
Reasons for not complying
Unable to afford transport
Unable to get transport
Lack of motivation
Thought they were cured
Knowledge of tuberculosis and knowledge scores
For each correct answer one point was awarded (to a
maximum score of six). The answers are summarised
in Table 3. The mean (SD) knowledge score for the
compliant group was 4 (1.2) and for the non-compliant
group it was 3.5 (1.34).
The difference between the groups was not statisti-
cally significant (P  0.089). However when the ques-
tions were analysed individually, a significantly greater
proportion of compliant patients correctly answered
the question: “Can treatment be stopped once you are
symptom free even though the prescribed treatment
duration has not been reached?” (P  0.01).
Reasons for non-attendance
The reasons given by non-compliant patients for not
attending the clinics are shown in Table 4. The major-
ity said that cost and availability of transport were
the main problems.
Suggested changes to the DOTS strategy
The results of the suggested improvement to DOTS
are displayed in the Figure. No spontaneous sugges-
tions were made. Only 10% of patients interviewed
suggested that there was no way in which DOTS
could be improved; these were all patients in the com-
pliant group. Many of the patients suggested more
Figure DOTS improvements: opinions of compliant and non-compliant patients.
than one improvement for DOTS. A high proportion
% of
of the patients (72%) indicated that they would like
patients more information about tuberculosis. The patients in
55
the non-compliant group were more keen to improve
17 the strategy, and 95% indicated that they would like
14 more information about tuberculosis.
14
DISCUSSION
This study shows that a major factor influencing com-
pliance with DOTS is the cost and time of travelling
to a treatment centre, as non-compliant patients pay
significantly more than compliant patients. Of the
non-compliant group, 55% indicated that they had
not attended the clinics for financial reasons. The pro-
vision of free drugs alone is therefore not sufficient.
Possible solutions to this problem may be to provide
a mobile service or to provide travel aid for the very
poor. Of the whole population in this study, 44%
indicated that financial aid would improve the sys-
tem, although some patients felt that financial aid was
a potential area for abuse. The introduction of reim-
bursement on production of a receipt may reduce
such a potential. The investment of resources required
for such measures might prove cost effective if
improved compliance results in fewer relapses and
less drug resistance.
The non-compliant patients also spent more time
travelling to the treatment centre than the compliant
patients. The time spent travelling to the centre could
be used for other purposes. This was reflected by the
opportunity cost statistic that indicated that the oppor-
tunity cost of travelling to the centres was higher for
non-compliant than compliant patients. For those in
employment, travel time represents time absent from
work, and although this was not specifically explored

in this study, it may explain why there were more
white collar workers among the non-compliant and
more non working patients among the compliant
group.
No data were available on the geographical dis-
tances that the patients lived from the health facilities,
but it was felt that travel time and cost would be more
relevant to patients than simple kilometres.
After correcting for travel time and cost, there was
no significant difference between the natives and non-
natives’ compliance rates. This is consistent with the
study by Liam et al.,3 which found no relationship
between compliance and immigration status.
When patients were asked for their views on how
treatment could be improved, 74% of the total and
95% of the non-compliant patients replied that they
would like more information. Either information
about tuberculosis is not being given, or the informa-
tion that is given is not understood. This was reflected
in the assessment of knowledge about TB, where very
few patients scored full marks. In contrast to previous
studies,4 we found no differences in the overall knowl-
edge scores between the groups. However, non-
compliant patients were more likely to think they
were cured when their symptoms had ceased, even
though the full course of treatment had not been com-
pleted. This was consistent with other studies that
found that this was a cause for patients defaulting on
treatment,5 and needs to be addressed. Compliance
with anti-tuberculosis treatment is enhanced if
patients receive adequate educational programmes.6
Information about tuberculosis has been demon-
strated to be most effective when given as one-to-one
counselling.4
Family members were affected in significantly
more of the non-compliant than the compliant group.
This may be because non-compliant patients are more
likely to pass the disease on to their contacts, but
there may be other factors, such as the increased cost
burden on the family affecting compliance, or altered
attitudes to the disease. However, this also represents
an opportunity, in that involving families, and not
just the current patient, in tuberculosis education may
help to improve compliance. Involving the family in
treatment was advocated by 50% of the patients.
As the sampled population were patients with an
active interest in the disease, it is apparent that more
health education programmes are required for the
whole population in Sabah. Such education pro-
grammes should include more accessible information
sources, such as patient information leaflets, posters
and radio and television advertising. Mobile road
shows might be considered in less accessible areas, in
schools, and in the workplace.
Weaknesses of this study
The sample size of this study would ideally have been
larger, but was limited by our ability to interview
Factors affecting compliance with DOTS 311
patients. Neither interviewer spoke Malay, and nurses
were used to interpret the questions for patients.
The patients in the compliant group were at vari-
ous stages in their treatment, and it is possible that
some may have become non-compliant later. The
effect of this on our results would be to reduce the dif-
ferences found between the groups. A study limited to
compliant patients completing treatment may over-
come this, but it was not possible within the time
available.
Tracing the patients who had failed to attend for
treatment was a difficult task. Tracing defaulters in
urban squatter communities frequently results in fail-
ure.7 There may therefore be a selection bias in the
non-compliant group in this study.
CONCLUSION
Patient compliance with DOTS in the Kota Kinabalu
area of Sabah is affected by travel expenses and the
amount of time that patients must spend travelling to
treatment centres, knowledge of the importance of a
full course of treatment, and having family members
who have had the disease. This study suggests that
reducing travel costs, travel time and the opportunity
cost of attending clinics for tuberculosis patients in
the Kota Kinabalu area of Sabah may improve com-
pliance rates. This may be achieved by having more
clinics or a more mobile service. Improved education
for patients, their families and the general population
may also improve compliance.
Acknowledgements
We are grateful to the Central Department for Public Health, Kota
Kinabalu, Sabah, Malaysia, for assistance with the study, and Dr
Bailey for help with statistical analysis.
Financial sponsorship was received from LEPRA, the Associa-
tion of Physicians, the Centenary and Hardwick Fund and the
Dora Ratcliff Memorial Fund, UK.
References
1 Plan of Action, Tuberculosis Control Programme, Sabah
1998–2001. Sabah: Unit of Infectious Diseases, Health Dept,
2000.
2 Guidelines for chemotherapy of tuberculosis. Kuala Lumpur,
Malaysia: Ministry of Health Malaysia, National Tuberculosis
Centre, 1994.
3 Liam C K, Lim K H, Wong M, Tang B. Attitudes and knowledge
of newly diagnosed tuberculosis patients regarding the disease,
and factors affecting treatment compliance. Int J Tuberc Lung
Dis 1999; 3: 300–309.
4 Cuneo W, Snider D E. Enhancing patient compliance with tuber-
culosis therapy. Clin Chest Med 1989; 3: 375–379.
5 Mori T, Shimao T, Jin B W, Kim S J. Analysis of case finding pro-
cess in Korea. Tubercle Lung Dis 1992; 73: 225–231.
6 Morisky D, Malotte C, Choi P. A patient education programme
to improve adherence rates with anti tuberculosis drug regi-
mens. Health Educ Q 1990; 17: 253–267.
7 Beyers N, Gie R, Schaaf H. Delay in the diagnosis, notification
and initiation of treatment and compliance in children with
tuberculosis. Tubercle Lung Dis 1994; 75: 260–265.
312 The International Journal of Tuberculosis and Lung Disease
C A D R E : Kota Kinabalu et les collectivités voisines à
Sabah en Malaisie.
O B J E C T I F S : Déterminer les facteurs influençant l’adhé-
sion des patients à l’égard d’une chimiothérapie anti-
tuberculeuse, leur connaissance de la maladie et leur
vision sur l’amélioration du système DOTS.
S C H É M A : Interviews de patients adhérents fréquentant
les dispensaires pour traitement DOTS et de patients
non-adhérents à leur domicile entre août et septembre
2000.
R É S U L T A T S : On a interviewé 63 patients adhérents et
23 non-adhérents. Pour les patients non-adhérents, le
fait de se rendre au centre de traitement entraînait un
coût plus élevé (P  0,005) et un temps de déplacement
plus élevé (P  0,005) par comparaison aux patients
adhérents. Le coût du transport a été la raison la plus
fréquemment citée pour la non-fréquentation. Les
patients non-adhérents étaient plus susceptibles d’avoir
MARCO DE REFERENCIA : Kota Kinabalu y las comu-
nidades vecinas, en Saba, Malasia.
O B J E T I V O S : Determinar los factores que afectan el cum-
plimiento del tratamiento antituberculoso, el conoci-
miento de los pacientes sobre la enfermedad y su opinión
sobre el mejoramiento del sistema DOTS.
M É T O D O : Entrevistas de los pacientes cumplidores que
asisten a los dispensarios para el DOTS y de los pacientes
no cumplidores en sus domicilios, durante agosto y setiem-
bre de 2000.
R E S U L T A D O S : Se entrevistaron 63 pacientes cumpli-
dores y 23 no cumplidores. Para los no cumplidores, lle-
gar al centro de tratamiento significaba un costo (P 
0,005) y un duración del viaje (P  0,005) superiores, en
comparación con los cumplidores. El costo del trans-
porte fue la razón más frecuentemente dada para justifi-
car la ausencia. Los no cumplidores tenían más probabi-
lidades de haber completado la educación secundaria
RÉSUMÉ
terminé leur formation secondaire (P  0,05) et d’être au
travail (P  0,01). L’atteinte de membres de la famille
était plus fréquente chez les patients non-adhérents (P 
0,01). On n’a pas observé de différence entre les groupes
en ce qui concerne les scores de connaissance de la tuber-
culose. Toutefois, les patients non-adhérents étaient plus
susceptibles de penser que le traitement peut être arrêté
après disparition des symptômes (P  0,01). La plupart
des patients (73%) pensent que le système DOTS pour-
rait être amélioré si l’on fournissait plus d’informations
au sujet de la tuberculose.
C O N C L U S I O N : L’adhésion à l’égard du DOTS dans la
zone de Kota Kinabalu est influencée par les dépenses de
transport, le temps nécessaire pour se rendre dans les
centres de traitement et la présence d’une maladie chez
d’autres membres de la famille. Les patents souhai-
teraient plus d’informations au sujet de la tuberculose.
RESUMEN
(P  0,05) y de estar trabajando (P  0, 01). Un número
más importante de no cumplidores tenían miembros de
la familia afectados por la tuberculosis (P  0,01). No se
constató una diferencia entre los grupos con respecto a
los «scores» de conocimientos sobre la tuberculosis. Sin
embargo, los no cumplidores tenían más probabilidades
de pensar que el tratamiento puede ser suspendido
cuando desaparecen los síntomas (P  0,01). La may-
oría de los pacientes (73%) pensaban que el sistema
DOTS podría ser mejorado si se diera más información
acerca de la tuberculosis.
C O N C L U S I Ó N : El cumplimiento del DOTS en el área de
Kota Kinabalu está afectado por los gastos de trans-
porte, por el tiempo necesario para dirigirse al centro de
tratamiento y por la presencia de un enfermo en la
familia. Los pacientes desean más información sobre
la tuberculosis.