Nonadherence to Antituberculosis Medications: The Impact of Stigma and Depressive Symptoms

Abstract

Medication nonadherence is common among tuberculosis (TB) patients in China and is of great concern. Herein, we determined the incidence of nonadherence in TB patients in central China and the impact of stigma and depressive symptoms on adherence; these issues are relatively unexplored. A cross-sectional survey was performed, and 1,342 TB patients were recruited from TB dispensaries in three counties in Hubei province using a multistage sampling method. The patients completed structured questionnaires that addressed medication adherence, TB-related stigma, and depressive symptoms. The independent effects of stigma and depressive symptoms on adherence were determined via multinomial logistic regression analysis. The mean medication adherence score was 6.03 ± 1.99. The percentage of TB patients with high, medium, and low medication adherence was 32.12%, 34.58%, and 33.31%, respectively. The impact of stigma and depressive symptoms on medication adherence was significant. TB patients with medium (odds ratios [OR]: 1.54, 95% confidence interval [CI]: 1.08-2.21) or high (OR: 5.32, 95% CI: 3.34-8.46) stigma or patients with mild (OR: 1.92, 95% CI: 1.34-2.75) or severe (OR: 3.67, 95% CI: 2.04-6.61) depressive symptoms showed a higher likelihood of having low adherence than those with low stigma or without depressive symptoms. TB-related stigma and depressive symptoms were common among TB patients in China, as was nonadherence, and independently associated with their adherence behavior. Social and psychological interventions that combat stigmatization and depression in TB patients should be adopted and optimized to improve medication adherence.

Association between tuberculosis and depression on negative outcomes of tuberculosis treatment: A systematic review and meta-analysis

“…One study reported an adjusted hazard ratio of 3.46 for treatment default or death in patients with symptoms suggestive of a major depressive episode (MDE) at baseline visit [3], while another also found an increased risk for loss to follow-up and death (RR = 9.09 and 2.99, respectively) in persons with an MDE score suggestive of depression at baseline [20]. In the largest study measuring depression, the authors showed that in comparison with individuals with low depression scores, those with high scores had a greater chance of poor medication adherence (OR = 3.67) [18]. In this study non-adherence was measured using the Morisky Medication Adherence Scale (MMAS-8) [21], another study reported a statistically significant mean difference between adherent and non-adherent individuals (7.14 vs. 2.55, p<0.001) [22].…”

“…All studies that measured depression among TB patients had a longitudinal design with the exception of Yan et al which was a cross-sectional study [18]. Depression was measured using both a 5-item and full version of the Center for Epidemiological Studies-Depression (CES-D) scale, the Patient Health Questionnaire (PHQ-9) scale, and by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) diagnostic criteria.…”

“…Furthermore, within each measurement of exposure, different psychometric instruments and cut-off scores were employed. In the case of studies that measured DS, there was notable variability between the scales used: a brief 5-item and the full 20-item version of the CES-D scale, and the PHQ-9 scale [3,18,20]. Others reported results using the exposure as a numeric variable alone [22,23].…”

“…For instance, one study used the MMAS-8 with scores of eight or higher and lower than six suggesting high and low adherence, respectively; other studies measured adherence by asking the participants to estimate their percentage of treatment compliance in the previous three or four week interval, with less than 90% classifying as non-adherence [25,26]. While these two found no association between PD and treatment adherence, another study found a strong association between DS and adherence [18]. The lack of consistency in both the definitions of exposure and outcome may contribute to these seemingly contradictory results.…”

An Evaluation of Medication Adherence in Tuberculosis Patients Based on Theory of Planned Behavior

“…The analysis of questionnaire in this study showed that 94.2% of respondents feel disturbed and uncomfortable with treatment program of TB that requires them to take their medication every day for a long time, perhaps because of the lack of social and psychological support from their family and their nearest person as documented in some previous research.A study in South Africa showed that good social support can improve adherence in TB patients (Akeju, Wright and Maja, 2017). Social and psychological interventions should be optimized to improve medication adherence in TB patients (Yan et al, 2017). Good medication adherence can be achieved by utilizing social influences through education in family members about how to support medication adherence to their family (Kopelowicz et al, 2015).…”