ABSTRACTS

Background:- efforts to improve treatment outcomes require a better understanding

of the particular barriers and facilitators of adherence to TB treatment, and patient
experiences of the taking treatment.
Objectives:- The aim of this study is to find factors that influence tuberculosis
treatment adherence in negele hospital and some selected health centers, guji zone,
oromia Region 2005 E. C

Methods:- A cross- sectional study using structured questionnaire was conducted. A

total of 210 study subjects were included in this study and the inquiry was made
based on all issues addressed in the structured questionnaire prepared in English
version in two Health centers, (Adola Woyu and Shakiso) and Nagele Hospital E.C.

Results:- The finding indicates that socio-economic factor like income has direct
effect on the adherence of anti TB treatment, 170(81%). The knowledge of the
patient was also found to be the great factor that affects the adherence which is
88(42%). The other factor can be the presence or absence of TB treatment supporters
which accounts 84(41%). This indicates that the absence of TB treatment supporters
led to quitting or unable to adhere to their drugs. The educational level particularly
illiteracy (34%) was another factor which directly related with knowledge of the
patients.

Conclusion and Recommendation:- the major reasons for non-adherence to the

treatment were low income and knowledge of the patients. And establishment ot TB
treatment following patients’ association to generate income of their own is
recommended to wereda health office, the health centers and hospital in
collaboration.

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Acknowledgment
I am grateful to God forgiving me the opportunity to work on this research paper. I
would like to give thanks to my advisor fanta for his constrictive advice and
guidance. My thanks also go to Guji zonal health office staff and martha berchu my
lovely wife for their support and co-operation for the study.
My thanks and appreciation also goes to department of pharmacy and SRP office of
jimma university for giving me this opportunity to conduct the study.

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Contents
ABSTRACTS........................................................................................................................................................................1
Acknowledgment.............................................................................................................................................................. 2
Chapter one....................................................................................................................................................................... 6
1 Introduction................................................................................................................................................................6
1.1 Background......................................................................................................................................................... 6
1.2 statement of the problem.........................................................................................................................................9
1.3 significance of the study........................................................................................................................................10
Chapter two.....................................................................................................................................................................10
2 Literature Review.....................................................................................................................................................10
Chapter three...................................................................................................................................................................13
3 Objective of the study.............................................................................................................................................. 13
3.1 general objective................................................................................................................................................... 13
3.2 specific objectives.................................................................................................................................................14
Chapter four.................................................................................................................................................................... 14
4 method and materials............................................................................................................................................... 14
4.1 study area and period.............................................................................................................................................14
4.2 Study design..........................................................................................................................................................14
4.3 population...........................................................................................................................................................15
4.3.1 source of population.......................................................................................................................................15
4.3.2 study population.............................................................................................................................................15
4.3.3 sampling technique.........................................................................................................................................15
4.4 study variables.......................................................................................................................................................15
4.4.1 dependent variable..........................................................................................................................................15
4.4.2 independent variable.......................................................................................................................................15
4.5 data collection and instrument...............................................................................................................................15
4.6 data analysis and interpretation.............................................................................................................................15
4.7 ethical consideration..............................................................................................................................................16
4.8 pretest....................................................................................................................................................................16
4.9 limitation of the study............................................................................................................................................16
Chapter five.....................................................................................................................................................................16
5. Results.....................................................................................................................................................................16
5.1 socio-demographic character.................................................................................................................................16
5.2 patient-related factors............................................................................................................................................18
5.3 socio-economic factors..........................................................................................................................................19

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 5.4 healthcare system-related factors...........................................................................................................................20
5.5 knowledge of tuberculosis and treatment..............................................................................................................23
5.6 default factors........................................................................................................................................................23
5.7 stigma and discrimination......................................................................................................................................25
5.8 Disease and medicine related factors.....................................................................................................................25
Chapter six...................................................................................................................................................................... 26
6 Discussion................................................................................................................................................................ 26
Reference........................................................................................................................................................................ 29

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Chapter one

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1 Introduction

1.1 Background

Tuberculosis,(TB) is an infectious bacterial disease caused by mycobacterium

tuberculosis, which most common affects the lungs. It is transmitted from person
to person via droplets from the throat and lungs of people with the active
respiratory disease.

One third of the world’s population is thought to have been infected with
M.tuberculosis, with new infections occurring at a rate of about one per second. In
2007, there were an estimated of 13.7 million chronic active cases globally,while
in 2010, there were an estimated of 8.8 million new cases and 1.5 million
associated deaths, mostly occurring in developing countries. The absolute number
of tuberculosis cases has been decreasing since 2006 and new cases have
decreased in 2002. the distribution of tuberculosis is not uniform across the globe;
about 80% of population in many Asian and African countries taste positive in
tuberculin tests, while only 5-10% of the united states population tastes positive.
More people in the developing world contract tuberculosis because of
compromised immunity largely due to high rates of HIV infection and the
corresponding development of AIDS.

In many countries globally, the adoption of Directly Observed Treatment (DOT)

has been associated with reduced rate of treatment failure, relapse and drug
resistance. However, its impact in reducing TB incidence has been limited by non-
compliance to DOT, which occurs when patients do not turn up for treatment at the
health facility or community DOT point. In countries where DOT has had little
impact on TB control, poor or non-compliance to self administrated TB treatment

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is common and has been identified as an important cause of failure of initial
treatment, leading to relapse.

Africa is facing the worst tuberculosis epidemic since the advent of the antibiotic
era. Driven by a generalized human immunodeficiency virus (HIV) epidemic and
compounded by weak health care system, inadequate laboratories, and conditions
that promote transmission of infections, this devastating situation has steadily
worsened, exacerbated by the emergency of during-resistant strains of tuberculosis.

Africa home to 11% of the world’s population, carries 29% of the global burden of
tuberculosis cases and 34% related deaths. The world health organization (WHO)
estimates that the average incidence of tuberculosis in African countries more than
doubled between 1990 and 2005, from 149 to 343 per 100,000 populations a stark
contrast to the stable or declining rates in all other regions during this period. In
1990, two African countries, Mali and Togo, had an incidence greater than 300 per
100,000; by 2005, 25 countries had reached that level, and 8 of them had an
incidence at least twice greater than 17 countries.

As one the millennium Development Goals, the united nations aims to reduce the
global prevalence of tuberculosis and mortality associated with tuberculosis of 50%
of their 1990 levels. Yet a 2006 WHO report, The Global plan to stop TB, 2006-
2015, suggests that this goal is unattainable in Africa, where more than half a million
people die each each year from tuberculosis. Africa desperately needs substantially
increased investments in research health care systems diagnostic laboratories, human
resources, and public health services if it is to shed its heavy burden of suffering and
death.

Ethiopia ranks seventh among the 22 countries with high TB burden, and third only
to south Africa and Nigeria in Africa, with an estimated incidence of all forms of TB

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at 378/100,000 in 2009. This means that among every 100,000 Ethiopians, 378 new
cases of TB were estimated to have occurred in 2009. The estimated incidence of
smear-positive (a form of TB in which TB bacteria seen when sputum smear is
stained and examined under the microscope) is 163 per 100,000 populations. If the
population of the Ethiopia is assumed to be 80 million then 302,400 new cases of all
forms of TB and 130,400 new smear positive TB cases were expected to have
occurred in the country in 2009. However, of the estimated figures, only 145,924
(48%) of all forms of TB cases and 44,593 (34%) of estimated new smear-positive
TB cases were actually detected. This suggests that the number of TB cases detected
in Ethiopia in 2009 is far below the expected numbers.

The global target for TB control is to detect at least 70% of the smear-positive cases
and cure at least 85% of the detected cases. If TB cases are not detected as they occur
in the communities, it means that people who are sick with active TB will continue to
spread the disease among the healthy population and many people will continue to
suffer and /or die in our countries. In this case of Guji zone there is high prevalence
of TB cases occurring in between around 500-1000 cases in each quarter of year.the
global case detection target and cure rate targets are far below achievements in this
zone. There is also high default rate in this zone. Efforts to improve treatment
outcomes require a better understanding of the particular barriers to and facilitators of
adherence to TB treatment, and of patients experiences of taking treatment.
Qualitative research can contribute to this understanding. This research is to target
factors behind the patients default from treatment program and to put
recommendations forward so that it may be base for another research and have
significant benefit for concerned bodies.

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1.2 statement of the problem
The WHO global plan to stop TB strive to halt and reverse its incidence by 2015 and
halve the 1990 prevalence and death rates by 2015. while these goals may appear
ambitious they can be achieved through good TB programs that ensure early case
detection and treatment by putting all patients on treatment and by ensuring by
complete its. Whereas these plans and targets are their global burden of TB remains
enormous. In 2011 there were an estimated 8.7 million new cases of TB (13% co-
infected with HIV) and 1.4 million people died from TB, including almost one
million death among HIV-negative individuals and 430000 among people who were
HIV-positive. TB is one of top killers of women, with 300000 deaths among HIV-
negative women and 200000deaths among HIV-positive women in 2011. Global
progress also conceals regional variation: the African and European regions are not
on track to halve 1990 levels of mortality by 2015.

The WHO ,in its global plan to stop TB, reported that poor treatment has resulted in
evolution of mycobacterium TB strains that do not respond to treatment with
standard first line combination of anti-tuberculosis medicines, resulting in the
emergency of multi-drug resistance tuberculosis (MDR-TB) in almost every country
of the world.

One of the greatest dilemmas and challenges facing most TB programs is that of
patients who do not complete their TB treatment for one reason or another. Such
patients are not only at risk of relapsing , but also they may develop resistance to one
or more of the potent first line TB medicines, such as Isoniazid (INH), Rifampicin
(R), Pyrazinzmide (PZA), Ethambutol (E) and Streptomycin (S).

The above mentioned points show how tuberculosis is problematic in each and every
corner of the world. Tuberculosis(TB) patients has difficulty following a long-term
treatment regimen.

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Efforts to improve treatment outcomes require better understanding of adherence as a
complex behavioral issue and of the particular barriers to and facilitators of patients
adherence.

1.3 significance of the study

Improvement in treatment outcomes requires a better understanding of the barriers
that the patients experience during TB treatment. The difficulty experienced by
patients in following treatment regimens has raised the awareness of adherence as a
complex behavioural issue. Therefore this study will reveal some the factors
associated with non-adherence to long term treatment regimen and the concerned
bodies can use the information of finding for the implementation to address the
problem. In addition the present finding foundation for further studies afterward.

Chapter two
2 Literature Review
Tuberculosis is a major cause of morbidity and mortality in Ethiopia. Which belongs
to the list of countries most affected more over compounded with HIV/AIDS. TB has
become a formidable threat to the country. Efforts made to identify and treat those
cases are far below satisfactory. This will further worsen our situation until the trend
is reversed.

A case control study done in Addis Abeba on defaulting from tuberculosis showed
that most of the defaulting occurred in the third and fourth months of treatment.
Social problems and feeling of improvement were the top two reason for patients for
default. It was also showed that inadequate knowledge, low education level, nearer
distance and negative attitude toward the TB center were found to be statistically
significant predictors for defaulting.

Another case control study at Addis Abeba tuberculosis centers how that major
factors contributing to high rates of defaulting were found to be lack of family

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support, inadequate knowledge about treatment duration and medication side
effects .it was recommended that control programmes that take these factors into
consideration should be successful in reducing defaulting.

Shargie. E and Lindtjorn. B recited that defaulting from treatment remains a

challenge for most tuberculosis control programmes. It was indicated that it may
increase the risk of drug resistance, relapse, death, and prolong infectiousness.
Aiming at determining factors predicting treatment adherence among smear-positive
pulmonary tuberculosis patients, it was have found that defaulting due to treatment
non-completion in their study setting is high, and the main determinants appear to be
factors related to physical access to a treatment center. They have got that
continuation phase of treatment was the most crucial time for treatment interruption.

A cross sectional study was conducted among patients with tuberculosis on the
DOTS regimen in the four teaching health centers of Jimma Zone to determine rate
of defaulting and factors associated with it. Accordingly it was showed that socio-
economic factors including distance of patients’ residence from the health institution
,lack of money for paying transportation and poor awareness about the disease were
the major reason contributing to poor compliance and defaulting. Manipulative
community based strategy for DOTS regimen inorder to make the drug available with
in the area of the grass root community and employing strong information education
and communication activities in order to reduce the default rate.

Another institution based cross sectional study conducted around rural north west
Ethiopia, Gonder revealed that tuberculosis treatment have significant social
consequences though it was before decades. Researchers have observed that social
ostracism to have been affecting tuberculosis patients and their family to a great
extent. Divorce rate due to tuberculosis among patients was 29.1%(37/127). patient
have reported loss or threat to lose their job. The TB control activities were

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ineffective and poorly organized . starting anti-tuberculosis treatment without proper
diagnosis was observed to have negative consequence s on the patients and the
control programme. In fact today launched health extension program might halt these
negative social consequences.

Sagbakken. M indicated that non-adherence to tuberculosis treatment is an important

barrier for TB control programs because incomplete treatment may result in
prolonged infectiousness, drug resistance, relapse and death in their qualitative study
carried out in Addis Abeba. It was found that loss of employment or the possibility to
work led to a chain of interrelated barriers for most TB patients. Daily treatment was
the time consuming and physically demanding , and rigid routines at health clinics
reinforced many of the the emerging problems. Patients with limited access to
financial or practical help from relatives or friends experienced that the total cost of
attending treatment exceeded their available resources. This was a barrier to
adherence already during early stage of treatment. A large group of patients still
managed to continue treatment, mainly because relatives or community members
provided food, encouragement and sometimes money for transport. Lack of income
over time, combined with daily accumulating cost and other struggles, made patients
vulnerable to interruption during later stages of treatment.patients who were poor due
to illness or slow progression, and who did not manage to restore their health and
social status were particular vulnerable to non-adherence. such patients lost access to
essential financial and practical support over time, often because relatives and friends
were financial and socially exhausted by supporting them. Ability to manage TB
treatment is a product of dynamic processes,in which social and economic costs and
other burdens change and interplay over time. Interventions to facilitate adherence to
TB treatment needs to address both time specific and local factors.

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Non-adherence dissertation in Taria of Nepal revealed that non-adherence seemed to
be related to treatment delivery failures. The health system needs strengthening in
Nepal. Intensified health care worker training and supervision, better health
education for patients and families. More flexibility for treatment supervisors,
adequate supplies for treatment centers and decentralization of treatment deliver to
the lowest health service level practicable are urgently needed.

A review of qualitative studies on tuberculosis treatment adherence indicated that

patients often take their TB medication under difficult circumstances and experience
significant challenges, many of which are outside of their direct control. Taking a
lengthy course of medication is not straight forward and frequently involves difficult
decisions, sometimes at substantial personal and social cost to the patient.adherence
is a complex, dynamic phenomenon; a wide range of interacting factors impact on
treatment-taking behavior, and patient behavior may change during the course of
treatment. More patient-centered interventions, far greater attention to structural
barriers, are needed to improve treatment adherence and reduce the global disease
burden attributed to TB.

Chapter three
3 Objective of the study
3.1 general objective
To asses factors that influence tuberculosis treatment adherence in negele hospital
and some selected health centers, guji zone, oromia

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3.2 specific objectives
To asses the relationship between health system factors and tuberculosis treatment
regimen adherence.

To asses the relationship between patients related factors and tuberculosis treatment
regimen adherence.

To asses disease and medicine related factors that influence tuberculosis treatment
regimen adherence.

To asses stigma and discrimination related factors that influence tuberculosis

treatment regimen adherence.

Chapter four
4 method and materials.
4.1 study area and period
The study was conducted in Nagele hospital and selected health centers in guji
zone .nagele is found in guji zone of oromia region at 610km from addis abeba to
south direction on 5’20N and 39’35E. the town has population of 4500 and zone has
a total population of 1642810 of which 831670 males, 811140 females. Lifestyle of
the people zone are farmers 68.1%, pastoralist 22.5% and merchants and others 9.4
%. the known mines found in the zone are gold, chromites, tantalum, mica,
iron,copper and nickel. (physical and socio economic profile of guji zone districts)

The zone bounded to east-bale zone, to south east-somale region, to south west-
borena zone and to north and north west-southern nations nationality peoples’ region.
There are two hospitals, 51 health centers; the study was conducted from feb;19-
23/2014.

4.2 Study design

A cross-sectional study design was conducted.

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4.3 population
4.3.1 source of population
All tuberculosis patients that registred for DOT program in negele hospital and
selected health centers.

4.3.2 study population

All tuberculosis patients on DOT program attended to TB clinic during the study
period.

4.3.3 sampling technique

No sampling technique was used.

4.4 study variables

4.4.1 dependent variable
 TB treatment adherence

4.4.2 independent variable

 Age

 Educational level

 Income

 Co-morbidity factors

 Stigma and discrimination

4.5 data collection and instrument

Questionnaire, containing open and close ended questions was used to collect the
appropriate data

4.6 data analysis and interpretation

All collected data was analyzed by using computer and respective interpretation was
drowned. The data were presented by using tables and figures.

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4.7 ethical consideration
The participant in this study were informed in their local language, including the
purpose of the study, the expected benefits of the study, and the process of data
collection. Refusal or consent had no effect on participant. Prior to conducting the
study, permission was obtained from of a nagele hospital and selected health center
through official letter from jimma university.

4.8 pretest
Some days before the actual data collection period testing of the questionnaire was
conducted and necessary modification was made before being applied on the study
participants.

4.9 limitation of the study

The limitation of the study was distance of the study area and very shortness of the
time given for data collection.

Chapter five
5. Results
5.1 socio-demographic character
A total of 210 individual were interviewed; about (56%) of them were males. Most of
respondents (44%) aged between 19-33 years. Most of respondents were Muslims
(37%) followed by orthodox (31%) and protestant (26%), with regard to literacy
status(41%) of respondents attended primary school (1-8), illiterate who cannot read
and write (34%), grade (9-12) were account (19%) and above grade 12 (6%). in terms
of language distribution, most of them (59%) spoke afan oromo followed by amharic
(32%), somali (5%) and sidama (2%). concerning marital status most of them (60%)
were married followed by single (30) and divorced (8%).

Table 5.1: the socio demographic characteristic of respondents in the selected health
facilities of guji zone, 2005 E.C

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Variable Character Frequency Percentage(%)

Age 1-14 14 7c

15-18 17 8

19-25 48 23

26-33 44 21

34-41 35 17

42-49 20 9

50-57 7 3

58-65 13 6

>66 12 6

Religion orthodox 65 31

Muslim 78 37

protestant 55 26

other 12 4

Gender Male 117 56

female 93 44

Marital status Married 125 60

Divorced 17 8

Cohabit 5 2

Widowed 1 0.5

single 30 30

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Language Afan oromo 143 49

Amaric 80 32

Tigiregna 2 0.9

Somali 13 5

Sidama 5 2

Other 4 1.9

Education Illiterate 71 34

Primary (1-8) 87 41

Secondary (9-12) 39 19

College and above 13 6

5.2patient-related factors

A total of 19 (9%) of the respondents reported having smoked cigarettes during the
previous six months. There were a low proportion of respondents who had smoked in
the previous six months in the total respondents. The respondents were also asked if
they had drunk alcohol in the last six months. The six months timing was expected to
coincide with the time the respondent had been taking TB treatment. A total of 31
(15%) drank alcohol in the previous six months while 173(82%) had not done so and
also 6 (3%) of them not remember whether they drank or not. Most 126 (59%), of the
patients had a treatment had a treatment supporter while they were taking treatment.

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5.3 socio-economic factors
The respondents were asked on the socio-economic factors and it was found that only
24 (11%) were employed, 51 (25%) were farmer and pastoralist, 49(23%) were house
wife and 33 (16%) reported being unemployed.

Table 5.2 distribution of socio-economic status of respondents in the selected health

facility of guji zone, 2005 E.C

Socio-economic status frequency percentage

Employed 24 11

Farmer 51 25

Merchant 26 12

Student 27 13

House wife 49 23

Unemployed 33 16

Total 210 100

For the respondents who were either employed or unemployed, a fellow up question
was to determine their level of income per month in selected health institution and it
was reported that 170 (81%) of respondents got less than 800 birr per month, while
32 (15%) earned 800-2000 birr per month and only eight of them earned greater than
2000 birr per month.

Respondents were asked to rate the availability of food while they were on treatment.
About , 126 (60%) of the respondent reported that food was always available to take
with their medicines, 14 (7%) said food was not always available and 70 (33%),
reported that food was available most of the time.

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5.4 healthcare system-related factors
Respondents were asked which TB clinic opening times were most convenient for
them. Almost all respondent convenient with opening time of TB clinic now days.

Respondents were asked how long they usually waited at the TB clinic before they
were attended. From a total of 210 responses were 161 (77%) of the respondents said
that they usually waited for less than an hour and two hours and 10 (5%) usually
waited for more than two hours.

Table 5.3 distribution of waiting time of the respondents in selected health facility of
guji zone, 2005E.C

Waiting time Frequency Percentage(%)

[<1 hour] 161 77

[1-2 hour] 39 18

[>2 hour] 10 5

Total 210 100

Most (92) patients interviewed collected their medicines from Nagele zonal
hospital,followed by shakiso health center (61) and adolawoyu health center(57).

The respondents were asked to indicate how much distance they travelled to go and
pick up their medicines.the majority of patients 148 (70%) travelled less than five
kilometers, while38 (18%) travelled between five and ten kilometers, 16 (8%)
between 11 and 15 kilometers, six (3%) between 16-20 kilometers and two (1%) still
had to travel more than 20 kilometers.

Table 5.4 distribution of distance travelled by respondents in selected health facility

of guji zone, 2005E.C

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Distance travelled (km) Frequency Percentage

[<5] 148 70

[5-10] 38 18

[11-15] 16 8

[16-20] 6 3

[>20] 2 1

Total 210 100

The respondents were asked to indicate how much they had to pay for transport to get
to the health facilities. Of the 210 respondents, 135 (64%) did not pay anything, 33
(16%) had to pay less than 5 birr, 28 (13%) between 6 and 10 birr, and five (2%) had
to pay more than 15 birr each time they went to the health facilities.

Table 5.5 distribution of cost of transportation of to go to the selected health facility

in guji zone, 2005 E.C

Cost of transport Frequency Percentage (%)

On foot 125 64

2-5 birr 33 16

6-10 birr 28 13

11-15 birr 5 2.4

16-20 birr 4 1.9

21-25 birr 1 0.5

Above 25 4 1.9

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Total (birr) 210 100

The respondents were asked who was supervising them while they had to take their
TB medicines. Of all the respondents, 191 (91%) were supervised by a health worker,
11 (5%) were supervised by a family member; 8 (4%) respondents were supervised
by a community member.

The respondents rated the attitude of health workers who attended them at the TB
clinic as follows; 77 (37%) very friendly, 132 (63%) friendly and 1 (0.5%) not
friendly.

Table 5.6: perception of respondents towards staff giving services in the selected
health facility of guji zone, 2005 E.C

Perception of respondents Frequency Percentage(%)

Very friendly 77 36.5

Friendly 132 63

Not friendly 1 0.5

Total 210 100

From all respondents 177 (84%) said that medicines were always at the clinic and
about 33 (16%)of them reported that drugs were not available sometimes when they
went to pick them.

5.5 knowledge of tuberculosis and treatment

Knowledge of TB and treatment was assessed with questions checking the
knowledge of the respondents of the common TB symptoms as well as duration of
treatment. Accordingly out of 210 respondents 118 (56%) said that TB treatment
should be taken for six months only and about 92 (44%) were not know exact time.

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5.6 default factors
About 166 (79%) of the respondents lived with their family, 26 (12%) lived alone
and 9 (4.5%) of them lived with friends.

Table 5.7 distribution of residence of respondents in the selected health facility of

guji zone,2005E.C

Residence Frequency Percentage (%)

Family 199 79

Friends 9 45

Alone 26 12

Others 9 45

Total 210 100

11 person lived alone; 67 (32%) lived with one to three others, 84 (40%) with four to
six and 35 (17%),with more than seven others.

Table5.8 distribution of number of people living with respondents in selected health

facility of Guji zone,2005 E.C

Number of people live with Frequency Percentage(%)

(0) 24 11

(1-3) 67 32

(4-6) 84 40

(>7) 35 17

Total 210 100

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Respondents were asked how many rooms their dwelling place or house had. Among
210 respondents 140 (67%) stayed in a house with one to two rooms, 62 (30%) lived
in a house with three to four rooms and 8 (3%) stayed in a house with more than five
rooms.

Table 5.9: distribution of number of rooms respondents have, guji zone, 2005 E.C

Number of rooms Frequency Percentage (%)

1-2 140 67

3-4 62 30

>5 8 3

Total 210 100

The length of stay in the current place was meant to measure the stability respondents
at a place. About 140 (67%) patients have lived in their current house for more than
12 months, thus most of the respondents were fairly stable or non-mobile.

Table 5.10 distribution of month stay at current place respondents in the selected
health facility of guji zone,2005 E.C

Month of stay Frequency Percentage (%)

(<3 months) 31 15

(3-12 months) 39 18

(>12 months) 140 67

Total 210 100

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5.7 stigma and discrimination
198 (90%) of the respondents of the patients had disclosed their TB status to either a
family or friends and 21(10%) were not disclosed to anyone. 22 patients who did not
disclose said “no one to trust” and “fear of being isolated by friends and relatives” as
the reasons for not doing so.

5.8 Disease and medicine related factors

72 (34%) of the patients had experienced some side effects while taking medicines
while 138 (66%) had not. Some of the respondent had more than one side effect. The
common side effects reported were skin rash (27), headaches and dizziness (21), pain
full limbs (16) and diarrhea and vomiting (9).

144 (69%) of the patients took the drugs for less than two months to feel better, 54
(26%) took between two and four months , 9(5%) of the respondents between five to
six months and three of them reported that they never felt better at all.

From 210 respondents, 92(44%) of them had smear positive pulmonary TB

(PTBSM+) while 80 (38%) smear negative TB followed by extra pulmonary TB
33(16%). 178 (86%) of the patients had HIV test result, while 41 (20%) of the
respondents with an HIV test result were HIV positive, 138 (66%) were HIV
negative and 11 (4%) with unknown status.

Respondents were asked if they were taking other medicines besides TB treatment. A
total of respondents 47 (22%) said that they were taking other medicines while 163
(78%) said they were not. Among those who taking other medicines 29 (61%) were
taking highly active Anti-Retroviral Therapy (HAART) and twelve were taking other
unspecified medicines.

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Regarding to the respondents seeking their opinion on what could make TB patients
complete their treatments. 18 (19%) of the respondents wanted food to be made
available for patients taking treatments, six (14%) wished collect their medicines
once for a week. The rest of the responses somewhat related with whether they eat or
not some kinds of food varieties like meat.

Chapter six
6 Discussion
Non-adherence to anti-TB treatment is the single most serious problem in TB control.
Unfortunately, health care providers and researchers have tended to see non-
adherence as patient problem ignoring environmental, structural and operational
factors. There are numerous factors that affect the adherence of anti TB treatment.
According to study socio-economic factor for example income has direct effect on
the adherence of anti TB treatment, (81%). the knowledge and attitude of the patient
was also found to be the great factor that affects the adherence which is (42%). The
other contributing factor could be the presence of TB treatment supporters which
accounts (41%). This indicates the absence of TB treatment supporters led to the
quitting or unable to adhere to their drugs. The educational level particularly being
illiterate (34%) is directly related with knowledge of the patients.

Presence or absence of food may have an effect on anti TB treatment adherence

(33%) which avails most of time only. Even though unavailability of anti TB drug
were relatively small in number (16%), it has great factor on anti TB treatment
adherence since one day interruption of taking drugs has its own negative impact on
adherence.

Different factors found to have an effect on treatment and contributed for non-
adherence of their medication. Distance of traveling 38(18%), drug side effect (34%)
and getting fill better (69%), long waiting time (18%) were the main other reasons

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for non-adherence of respondents. When compared with quantitative, cross-sectional,
descriptive and comparative study done by kudakwashe chani on factors affecting
compliance to tuberculosis treatment in Namibia, from 26 non adherent respondents,
distance 8(31%) was the main reason for non-adherence followed by feeling better
(27%), lack of family support 4(15%), no food 2(8%), side effects 2(8%). this is
dissimilar with the present study in which low income was the main reason for non-
adherence (22). This could be due to socio-economic difference and the distance
travelled by the study populations to get treatment between the study areas.

According to the cross-sectional study done by interviewed questionnaire in India,

87% of the respondents believe to stop anti TB treatment as soon as the symptoms
disappeared. However, in the present study 69% patients were non adherent due to
filling better.

The effect of socio-demographic factors such as age, gender, social status, smoking,
alcohol consumption, education level and occupation on the adherence to TB
treatment has been reported in several studies. The result have been controversial and
have yield different findings about the same determinant. The patient characteristics
cannot be controlled or significantly altered to improve treatment adherence.

In contrast, the present study social characters such as smoking and alcohol
consumption showed that no effects on TB treatment adherence. This may be due to
social make up or and behavioural difference.

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Reference

1. Demissie M, Kebede D. defaulting from tuberculosis treatment at the Addis Abeba

Tuberculosis Center and factors associated with it. Ethiopia Medical journal 1994,
32:97-106

2. Tekle B, Mariam DH, Ali A. defaulting from DOTS and its determinants in three
districts of Arsi Zone in Ethiopia, International journal Tuberculosis Lung Disease
2002, 6:573-579

3. Shargie EB, Lindtjorn B: Determinants of treatment adherence among smear

positive pulmonary tuberculosis patients in Southern Ethiopia, PLoS Med 2007,
4:e37

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4. Michael KW, Belachew T, Jira C, Tuberculosis defaulters from the “DOTS”
Regimen in jimma zone, south-west Ethiopia, Ethiopia Medical Journal 2004,
42:247-253

5. Getahun H, Argaw D, Tuberculosis in Rural North-West Ethiopia: Community

perspective, Ethiopia Medical Journal 2001, 39:283-291

6. Sagbakken M, Frich JC, Bjune G. Barriers and enablers in the management of

tuberculosis treatment in Addis Abeba, Ethiopia: a qualitative study, BMC public
Health 2008, 8:11

7. Wares DF, Singh S, Acharya AK, Dangi R. Non-adherence to tuberculosis

treatment in the eastern Tarai of Nepal, International Journal tuberculosis Lung
Disease 2003,4:e238

8. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient
adherence to tuberculosis treatment: a systematic review of qualitative research,
PLoS Med 2007, 4:e238

9. Kudkwash, C. Factor affecting compliance to Tuberculosis treatment in Namibia

Kayango, 1996

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Questionnaire

Jimma university

College of public Health and Medical sciences

Department of pharmacy

Individual patients questionnaire Number:---------------

Date of interview:_________________

Instructions:

Option is circled for all the questions.

Section A: Demographic Information

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1. Health facility_____________________

2. Age (in years)___________Sex_______

3. Religion: 1. Orthodox 2. Islam 3. Protestant 4. Other(specify)

4. Gender 1. male 2. female

5. Martial status 1. married 2. divorced 3.widowed 4. cohabiting 5. single

6. Language 1. afan Oromo 2. Amharic 3. Tigrigna 4. somali 5. sidama

6.Other(specify)

7. Educational level? 1.illiterate 2.primary 3.secondary(9-12) 4.collage and above

Section B: Patient Related Factors

8. Have you smoked cigarettes in the last 6 months?

1. yes 2.no 3.cannot remember

9. Have you drink alcohol in the last 6 months?

1. yes 2.no 3. cannot remember

10. Do you have a treatment supporter?

1. yes 2.no

Section C: Socioeconomic variables

11. socioeconomic status 1.employed 2.farmer 3.merchant 4.student 5.house wife

6.unemployed

12. What is your income (per month)? 1.low(<800) 2.medium(800-2000)

3.high(>2000)

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13. During the time you were taking TB medicines, what would you say about your
situation in terms of food availability? 1.always available 2.available most of time
3.not always available 4.never available

Section D: Health-care system related

14. What would be the most convenient TB clinic opening times for you?________

15. How much time do you usually wait at the TB clinic before being attended? 1.
[<1hr] 2.[1-2hrs] 3.[>2hrs]

16. How much distance do you travel to collect your TB medicines?

1.[<5] 2.[5-10] 3.[11-15] 4.[16-20] 5.[>20]

17. How much does it cost you to get to the health facility?___________________

18. Who supervised you when you were taking your TB medicine? (DOT status)
1.none 2.family member 3.health worker at the facility 4.community member

19. How would you rate the attitude of staff who attended you at the health facility?
1.very friendly 2.friendly 3.indifferent 4.unfriendly 5.very unfriendly

20. When you went to pick your medicines at the TB clinic, what would you say
about the availability there? 1.always available 2.sometimes not available

21. I just want to take some time to find out what you know about TB. The following
is/are symptoms of TB

a) coughing [1.yes 2.no]

b) Night sweats [1.yes 2.no]

c) Loss weight [1.yes 2.no]

d) Chest pains [1.yes 2.no]

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22. TB treatment should be taken until [1.yes 2.no]

a) 6 months [1.yes 2.no]

b) One feels better then stop on your own [1.yes 2.no]

c) 6 months completed and health worker tells you to stop [1.yes 2.no]

Section E: Default factors

23. Who do you live with? 1.family 2.friends 3.alone 4.other

24. How many other people live with you? 1.(0) 2.(1-3) 3.(4-6) 4(>7)

25. How big is your dwelling/ house (number of rooms)? 1.(1-2) 2.(3-4) 3.(>5)

26. How long have you stayed in your current dwelling/ house? 1.
(<3months) 2.(2-12months) 3.(>12months)

Section F: Stigma and discrimination

27. Did you inform your family of friends that you were on TB treatment? 1.yes 2.no

28. If no, why? 1.fear of being isolated by friends or relatives 2.no one trust 3.other

Section G: Disease and Medicine related

29. Did you experience any side effects when you were taking TB treatment?
1.yes 2.no

30. If yes to above question, which side effects did you experience?

1. Diarrhea & vomiting

2. Headaches & dizziness

3. Skin rashes

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4. Numb feet or hands

5. Yellow eyes

6. Painful limbs

7. Others

31. From the day you started taking your TB medicines, how long did it take you
before you felt better? (months) 1.[<2] 2.[2-4] 3.[5-6] 4[did not feel better]

32. Did you complete your TB treatment? 1.yes 2.no

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