What works best for ensuring treatment adherence. Lessons from a social support program for people treated for tuberculosis in Ukraine

Abstract

Background Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Ukraine is one of 30 countries with the highest burden of multidrug-resistant tuberculosis. Global literature shows that social support (SS) is important in improving TB treatment adherence, reducing lost to follow up rates and improving treatment outcomes. There are several models of SS available, and the literature provides little information on what aspects of SS are most important to TB patients in improving their adherence. Methods We used qualitative data collected through in-depth interviews (IDI) with 21 TB patients and 15 SS providers and coordinators in Ukraine in August-September 2016 to understand how the SS program promoted treatment adherence among patients. We examined the aspects of outpatient TB treatment that made adherence particularly difficult for patients in at-risk groups and aspects of the SS programs that worked best for addressing those barriers. Interviews were transcribed and analysis was performed to derive emergent themes. Results Main barriers included side effects from medicine, the amount of time required daily for transportation and waiting in lines at the health facility, transportation expenses, risks of being identified when visiting a TB facility and lack of motivation to seek treatment. Features of the SS program most valued by patients were convenience of not having to visit facility and support provided by nurses. These two features directly addressed most of the barriers identified. The commitment and qualities of the nurses that provided the SS was an important element of the program. Conclusions This qualitative study suggests that the SS program in Ukraine was successful in reducing treatment default among patients at high risk of default because it directly addressed most of the major barriers they faced to treatment adherence.

Patients’ perspectives of tuberculosis treatment challenges and barriers to treatment adherence in Ukraine: a qualitative study

“…These challenges emerged as factors that undermine treatment adherence and are consistent with identified adherence barriers in other sociopolitical contexts, thus suggesting that interventions implemented successfully elsewhere would be appropriate for consideration in Ukraine. A recent qualitative study among patients with TB in Ukraine similarly identified the inconvenience and cost of clinic-based DOT during the ambulatory phase of treatment as major challenges to treatment adherence 31. Our study provides additional insights into how hospitalisation and patient interactions with TB providers adversely influence adherence in the context of TB services in Ukraine.…”

“…A prior analysis of UNTP has concluded that hospital-based TB care contributes to poor outcomes,30 and the latest UNTP guidelines recommend outpatient management of DSTB 12. Moreover, a pilot study in Ukraine recently reported home-based DOT facilitated retention in TB care 31. Ongoing reorganisation of TB care in Ukraine will provide opportunities to assess how full-scale implementation of home-based DSTB treatment influences patients’ experiences and treatment outcomes.…”

“…There is ample evidence that patient–provider relationships characterised by trust, mutual respect and shared decision-making facilitate adherence to chronic disease therapy 27 36–38. A recent evaluation of a social support programme for patients with TB in Ukraine reported that excellent rapport and communication marked by respect and empathy from nurses was a key driver of success in patient retention 31. Given the psychological difficulties associated with TB, more supportive attitudes from providers might improve patient willingness to remain in care.…”

“…Many participants discussed the economic burden of TB treatment. Poverty is a risk factor for TB disease, and TB treatment exacerbates existing financial hardship and impairs treatment adherence 25 27 31 43–45. Studies have shown that cash transfers, and assistance with food and transport can increase treatment success rates 41 46.…”

“…Prior analyses of UNTP have enumerated institutional and political barriers to successful DOTS implementation10 30; however, only one qualitative study to date has assessed patient perspectives concerning barriers to treatment adherence in the specific context of TB care delivery in Ukraine 31. Notably, the WHO highlights patient-centred approaches to TB care as a critical component of TB control efforts 32.…”