Determinants of Default from Tuberculosis Treatment among Patients with Drug-Susceptible Tuberculosis in Karachi, Pakistan: A Mixed Methods Study

Abstract

PurposeNon-adherence to tuberculosis therapy can lead to drug resistance, prolonged infectiousness, and death; therefore, understanding what causes treatment default is important. Pakistan has one of the highest burdens of tuberculosis in the world, yet there have been no qualitative studies in Pakistan that have specifically examined why default occurs. We conducted a mixed methods study at a tuberculosis clinic in Karachi to understand why patients with drug-susceptible tuberculosis default from treatment, and to identify factors associated with default. Patients attending this clinic pick up medications weekly and undergo family-supported directly observed therapy.MethodsIn-depth interviews were administered to 21 patients who had defaulted. We also compared patients who defaulted with those who were cured, had completed, or had failed treatment in 2013.ResultsQualitative analyses showed the most common reasons for default were the financial burden of treatment, and medication side effects and beliefs. The influence of finances on other causes of default was also prominent, as was concern about the effect of treatment on family members. In quantitative analysis, of 2120 patients, 301 (14.2%) defaulted. Univariate analysis found that male gender (OR: 1.34, 95% CI: 1.04–1.71), being 35–59 years of age (OR: 1.54, 95% CI: 1.14–2.08), or being 60 years of age or older (OR: 1.84, 95% CI: 1.17–2.88) were associated with default. After adjusting for gender, disease site, and patient category, being 35–59 years of age (aOR: 1.49, 95% CI: 1.10–2.03) or 60 years of age or older (aOR: 1.76, 95% CI: 1.12–2.77) were associated with default.ConclusionsIn multivariate analysis age was the only variable associated with default. This lack of identifiable risk factors and our qualitative findings imply that default is complex and often due to extrinsic and medication-related factors. More tolerable medications, improved side effect management, and innovative cost-reduction measures are needed to reduce default from tuberculosis treatment.

Evaluation of tuberculosis defaulters in Yemen from the perspective of health care service

“…Many studies have reported similar results, i.e. 29% in Zambia, 13.7% in South Africa, 11% in Nairobi, 10% in Armenia, 14% in South India, 11% in Maharashtra‐India and 10% in Karachi, Pakistan . Other studies have reported that improved health condition occurs mostly during the intensive phase of treatment because the number of tubercle bacilli in the body is reduced, thus, the patient feels better .…”

“…Moreover, given the scarcity of laboratory tests to identify the comorbid conditions of TB patients in TB centres, such tests can be provided for free to suspected TB patients or prescribed to be conducted in outside laboratories to avoid bad treatment consequences and to decrease defaulter rate. Moreover, the management of side effects associated with treatment may play a major role in optimizing defaulter rate . Symptomatic treatment should be administered to TB patients with minor side effects.…”

“…A similar study conducted in Fez, Morocco showed that 26% of the sample defaulted due to treatment side effect, 28% was reported in Sub‐Saharan Africa, and 14% in urban Morocco . A study regarding the risk factors of defaulters in Karachi, Pakistan, which combined open end questionnaires with quantitative analysis, found that side effects was the major factor associated with defaulting . Approximately, 14.8% and 10% were reported in Thailand and Tashkent, Uzbekistan respectively .…”

“…Other studies from Ghana, Armenia, Eastern Nepal, Indonesia, Korea, India (9.6%), Brazilian Amazon, West Bengal, India and Busia, Kenya reported the same finding. Therefore, side effect should be controlled in Yemen because it plays a major role in lowering the rate of defaulting . This emphasizes the need for the development of more tolerable medications, enhanced management of side effects, and possibly early counselling for patients affected by significant side effects.…”

“…Most of these defaulters were from urban areas. The threat of being fired or dismissed from work can be a reason for defaulting . Others studies have reported financial difficulties due to low salary forced TB patients to default .…”