FACTORS CONTRIBUTING TO NON-COMPLIANCE TO

PULMONARY TUBERCULOSIS TREATMENT AMONG

PATIENTS IN BUDALIN TOWNSHIP

Proposed by:
Mg Aung Min Tun
IIMPA-1
MPA 18th Batch
 Contents
• Chapter 1: Introduction
1.1 Rationale of the study
1.2 Research Problems
1.3 Objective of the Study
1.4 Method of the Study
1.5 Scope and Limitation of the Study
1.6 Expected Outcomes
• Chapter 2:Literature Review
• Chapter 3:Tuberculosis situation in Budalin Township
3.1 Health Facilities in Budalin Township
3.2 Previous five years TB treatment outcomes
• Chapter 4:Analysis on factors contributing to non- compliance
to pulmonary TB treatment among patients in budalin township
• Chapter 5: Conclusion
 1.1.Rationale of the Study
• Tuberculosis (TB) is an infectious disease caused by
Mycobacterium Tuberculosis (MTB), which is transmitted
through the air or by ingesting infected milk or meat (Bovine
TB) and it is both preventable and curable (World Health
Organization 2006a:).
• People who have pulmonary tuberculosis (TB disease in the
lungs) can infect others through droplet infection when they
cough, sneeze or talk (WHO 2006a:5).
• The prevalence of TB among close contacts of infectious
patients can be about 2.5 times higher than in the general
population.
 Rationale(Cont’d)
• The World Health Organization (WHO) estimates that almost 9
million new patients develop TB each year, and that 1.8
million people died from TB globally in 2008 (WHO 2009:5).
• TB has a huge impact on patients, families and their
communities through spending on diagnosis, treatment,
transport to and from the health facilities and time lost from
work (WHO 2006c:24).
• However, if TB is detected early and fully treated, people with
the disease quickly become non-infectious and are eventually
cured.
 Rationale(Cont’d)
• The WHO, in its global plan to stop TB, reports 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 emergence of multi-drug resistance tuberculosis (MDR-
TB) in almost every country of the world.
• According to Laserson and Wells (2007:378), Multi-Drug
Resistant and Extensive Drug Resistant Tuberculosis (MDR-TB
and XDR-TB, respectively), Human Immunodeficiency Virus
(HIV) associated TB, and weak health systems are the major
challenges to TB control globally.
• One of the greatest dilemmas and challenges facing most TB
programmes is that of patients who do not complete their TB
treatment for one reason or another (Rieder 2002:84; WHO
2008a:6).
 Rationale(Cont’d)
• Such patients are not only at risk of relapsing, but they may
develop resistance to one or more of the potent first line TB
medicines, such as Isoniazid (INH), Rifampicin (RIF),
Pyrazinamide (PZA), Ethambutol (ETH) and Streptomycin (S).
• Resistance to both INH and RIF is defined as multi-drug
resistance TB (MDR-TB) and extensively as drug-resistance
(XDR-TB), as resistance to INH and RIF plus a Fluoroquinolone
and one of the second line injectable drugs, namely;
Capreomycin, Kanamycin or Amikacin (Namibia 2006:44;
WHO 2008b: 20).
 1.2.Research Problem
Background to the Problem
• 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 (Tessema et al 2009:5).
• According to records (Budalin NTP 2017), the Case Notification
Rate (CNR), which is defined as the number of TB patients
notified per 100,000 population during a particular period
(2017), was 270 per 100,000 population, that is a total of 393
TB patients diagnosed and reported. Of these, 95 were new
sputum smear positive patients.
 Background to the Problem(Cont’d)
• The TB epidemic in Budalin is thought to be due to a
multitude of factors that include poor housing, HIV infection,
alcoholism, poor nutrition and poor access to high quality
health services in hard to reach areas.
• Poverty has been cited as one of the main causes of this TB
epidemic as it is associated with overcrowding and poor
ventilation, enhancing high transmission.
• Compliance to TB treatment continues to be one of the major
obstacles that TB control programmes worldwide have to deal
with, especially in developing countries (Tessema, Muche,
Bekele, Reissig, Emmrich & Sack 2009:2).
• Thus, understanding the factors affecting to tuberculosis
treatment compliance in Budalin township could help address
issues to improve patient compliance to treatment and
improve health outcomes.
 Background to the Problem(Cont’d)
• Non-compliance can result in acquired drug resistance, which
requires a prolonged period of treatment with more
expensive medicines than treatment for drug-susceptible TB
(Caminero 2008:869; Chiang, Denn & Caminero 2006:827;
Singh, Upshur & Padayatchi 2007:20).
• Treatment with second line medicines is likely to be less
successful than treatment with first line drugs, mainly
because the second- line medicines are less potent and more
toxic, with a longer treatment period that makes it more
difficult for patients to complete it (Dye 2009:85; WHO
2008b:3).
 Background to the Problem(Cont’d)
• According to Caminero (2003:241), the main objective of TB
programmes in all countries is to interrupt the chain of
transmission by acting on the human reservoir of TB bacilli.
• The correct management of patients with TB is therefore
crucial, since most patients come for TB treatment with
treatable or drug-susceptible mycobacterium and only
develop resistance after the health worker has introduced TB
medicines which may be in incorrect doses, taken incorrectly
or for an insufficient duration.
• This study thus aims to explore the factors affecting to non-
compliance to TB treatment in Budalin township.
 Background to the Problem(Cont’d)
• In countries where DOT has had little impact on TB control,
poor or non-compliance to self-administered TB treatment is
common and has been identified as an important cause of
failure of initial treatment, leading to relapse.
 Problem Statement
• TB is one of the top 10 causes of death worldwide according to
the WHO.
• TB is one of the major public health problems in the world
including Myanmar.
• Taking the results of a nationwide TB prevalence survey (2009-
2010) into account, WHO estimated in its Global TB report 2015
that TB incidence in Myanmar was 369 per 100,000 population
and TB prevalence was 457 per 100,000 population in 2014.
• Myanmar ranks among the 30 worst nations in the world in
terms of TB burden and the mortality rate is 49 out of every
100,000 residents, according to 2015 data from WHO.
 Problem Statement(Cont’d)
• Defaulter patients was 6, and failure patients was 5 ,died
patients was 10 in Budalin township according to 2016
townshp data.
• Relapsing rate was 4.5 % in 2016, 4.8% in 2017 respectively in
Data source-Budalin township hospital

budalin township.This is mostly due to non-compliance of

anti-TB treatment by patients. These are a harbinger for drug-
resistant TB.
• Therefore, without knowledge of factors associated with
defaulting and poor compliance in this township, it will be
difficult to address the situation.
Multi-drug resistance
Year Retreatment Cases(RR)
TB cases(MDR)
2016 21 5
2017 19 8
2018 6 3
 1.3-Objectives of the Study
General Objective
• To explore and describe the reasons why pulmonary TB patients
were non-compliant to treatment in Budalin township.
Specific Objectives
 To determine the compliance patterns among TB patients in
Budalin Township;
 To assess the level of knowledge of TB patients in Budalin
township about TB treatment;
 To identify the socio-cultural factors responsible for non-
compliance with TB treatment among the TB patients;
 To identify the health-related factors which may result in non-
compliance to TB treatment among the respondents
Definition of the Key concepts
• Tuberculosis - a disease caused by mycobacterium
tuberculi infection (Caminero 2003:24).
• Compliance is the continuous, correct and uninterrupted
taking of prescribed medication as directed by the
healthcare professional (International Union Against TB
and Lung Disease (IUATLD), 201 0:12).
• In this study, Compliance will be defined as taking of
tuberculosis medication daily at the right time, at a
dosage in line with the TB treatment guidelines for about
6 months, with the correct diet and avoiding alcohol until
the patient is declared cured by a health-care professional
(Mokgoadi. 2002:18).
 Measuring compliance
• According to the National Department of Health (2005:1
09), compliance is a very important tool used in the
assessment of effectiveness and success of treatment.It
helps in monitoring changes in health outcomes based on
the recommended treatment regimen.
• In order to measure compliance to TB treatment, the
effectively implemented strategy recommended by the
WHO is the Directly Observed Treatment (DOT) strategy.
DOT means that an observer watches the patient
swallowing the tablets in the way that is sensitive and
supportive to the patients' needs. This ensures that a TB
patient takes the right drug, in the right doses, at the right
interval of time and for the right duration (WHO, 2000:78).
 Measuring compliance(Cont’d)
• Any poor compliance measured by missing 5
doses or more per month of the prescribed
medication, results in inadequate treatment
as well as drug resistance (WHO,2000:77).
• According to the WHO (2011 :27) in DOTS
programmes, almost twice as many patients
successfully complete their treatment as
compared to those in non DOTS programmes.
 Definition of Non-Compliance
• Non-compliance refers to the interruption of
tuberculosis treatment or missing doses during the
course of treatment (Swaziland Ministry of Health,
2006:49).
• In this study non-compliance will be defined as not
taking tuberculosis treatment daily for the
prescribed duration in accordance with the TB
treatment guidelines.This includes patients who miss
any dose(s) of the TB treatment for whatever
reason.
1.4.Scope and Method of the Study
• Study area is in Budalin Township, Sagaing region.
• There are 181 TB patients who have been taken anti-TB Treatment
between January and September, 2018.
• All adult 121 TB patients,15 years and above, who have been initiated on
TB treatment for 1 month or more will be selected to participate in this
study.
• Descriptive method will be used.
• The structured questionnaires will be distributed to the selected patients
to collect the primary data during December 2018 to March 2019.
• Patients will be interviewed at health facilities, their home or their
workplaces.
• Secondary data will be acquired from the Township TB register, World
Health Organization Website, National Tuberculosis Program and Internet
Website, and National Tuberculosis Reports.
• A quantitative, cross-sectional studies, will be used in this study.
 The instrument
• The questionnaire will be divided into the
following sections;
Section A: Demographic information;
Section B: Socioeconomic variables;
Section C: Client related factors;
Section D: Health system related factors;
Section E: Socioeconomic barriers; and
Section F: Disease and medicine related barriers
 Method of the study
• Chi square test will be used to compare
different proportions and the association
between variables.
• The 5% level of significance will be used as the
cut off for statistical significance.
• Descriptive statistics of frequency distributions
and measures of dispersion will be used to
describe study variables.
 Ethical considerations related to data
collection
• Ethical considerations related to data
collection in this study will be included the
principle of respect for human dignity,
principle of anonymity and confidentiality,
principle of beneficence and the principle of
justice.
 Limitations of the Study
• The scope of the study will be limited to adults
aged 15 years and above, hence views for
children will not be captured.
• Another limitation of the study is that the
target population will be patients who were
receiving treatment for at least 1 month thus
views for newly initiated TB patients will not
be captured.
 Figure;The Health Belief Model
Socio-demographic factors
• Sex
• Age
• Educational level
• Race
• Employment status

Perceived benefits of action Perceived susceptibility

• Knowledge about TB, treatment and
importance of compliance to treatment
Perceived barriers to action
•Socio-cultural and health related issues
affecting patients' compliance to TB
treatment
• Belief that you are sufferingfrom TB
• Belief that the TB diagnostic method
used is accurate
Perceived severity of ill health condition
• Perceptions or knowledge of dangers of
not complying to TB treatment

• Behaviour to reduce threat

based on expectations

Source: Umeh & Rogan-Gibson (2001 :361-673)

 2.Literature Review
• Patient compliance to TB treatment in Andara District, Kavango
region of Namibia is associated with the availability of food with
which to take medicines, patient waiting times at the TB clinic, and
feeling better on treatment.
• One of the important areas for TB control programmes is to
improve or enhance TB treatment compliance.
• This study suggests that reducing patient waiting times at the TB
clinic, making food available to patients on TB treatment through
linkages with social services and community programmes, and
improving patient TB treatment literacy would improve TB
treatment compliance in Andara district.
• The focus of TB treatment literacy should be at four levels, namely
patient, health worker, family and community( Kudakwashe Chani )
 Literature Review(Cont’d)
• Identified barriers to compliance include forgetfulness, lack of
transport fare on clinic appointment days, patients not feeling well
and so were not strong enough to attend clinic appointments.
• On the other hand, the role of treatment supporters and
counseling were found to have a positive impact on compliance to
DOT in this setting. The use of reminders such as cell phones and
alarm-radios were also identified as facilitators to compliance.
Patients’ knowledge of consequences for not taking medications
as prescribed, which is closely linked with counseling, was found
to be significantly associated with compliance in this study.
(OLAYINKA AYOBAMI AIYEGORO; Nov-2016,South Africa ).
 Literature Review(Cont’d)
• The factors identified in this study can be classified
into patient related factors, economic factors,
social factors and health care workers and health
system related factors. Furthermore, the factors at
these different levels impact on one another and
their improvements need to be made at all these
levels to address the challenges facing TB patients
to achieve optimal treatment compliance.
(OLAYINKA AYOBAMI AIYEGORO; Nov-2016- South Africa ).
 Literature Review(Cont’d)
According to Namibia (2007:108), some of the barriers postulated to
be contributing to poor TB treatment compliance are:

• communication difficulties
• low literacy levels
• inadequate knowledge and low awareness of TB disease
• patient attitudes and beliefs in treatment efficacy
• depression and other psychiatric illnesses
• alcohol and substance abuse
• unstable living conditions
• negative health provider attitudes
• stigma and discrimination
• overcrowding and access to medicines.
 Township Profile
 Total Wards-3
 Total Villages-188
 Total Population-149832
 3.1-Health Facilities in Budalin township
Sr.No. Health Facilities Number

1 50 bedded Township Hospital 1

2 16 bedded Station Health Unit 2

3 MCH 1

4 Rural Health Centre 6

5 Sub RHC 29

6 Traditional Medicine Clinic 1

Total 40
Data source-Budalin township hospital
 Man Power in Health Sector of Budalin
Township
Sr.No. Health Professionals Quantity

1 Doctors/Dentists 12

2 Nurses 27

3 Health Assistants 9

4 Lady Health Visitors /Midwives 43

5 Others 81
Total 172

Data source-Budalin township hospital

 3.2-Treatment Outcomes(2013-2017)
Non- Treatment
Sr.No. Year Total TB patients Compliance
Compliance Success Rate

1 2013 274 227 47 83%

2 2014 269 218 51 81%

3 2015 280 241 39 86%

4 2016 477 420 57 88%

5 2017 392 337 55 86%

Total 1692 1443 249 85%

Data source-Budalin township NTP report

 5.Expected Outcomes
The study will also contribute towards the
development of strategies aimed at:
• Increasing compliance to TB treatment; and

• Decreasing the TB defaulter rates and patients

lost to follow up.

• Improve the general outcomes of TB patients.

 References
• Caminero, JA. 2003. A tuberculosis guide for specialist
physicians. International Union Against Tuberculosis and Lung
Diseases: 24.
• KUDAKWASHE CHANI:(Nov-2010) FACTORS AFFECTING
COMPLIANCE TO TUBERCULOSIS TREATMENT IN ANDARA
KAVANGO REGION NAMIBIA by , HEALTH STUDIES,
UNIVERSITY OF SOUTH AFRICA
• Laserson, KF and Wells, CD. 2007. Reaching the targets for
tuberculosis control: the impact of HIV. World Health
Organization bulletin 85(5):377-381.
 References(Cont’d)
• Tessema, B, Muche, A, Bekele, A, Reissig, D, Emmrich, F and
Sack, U. 2009. Treatment outcome of tuberculosis patients at
Gondar University Teaching Hospital, Northwest Ethiopia. A
five-year retrospective study. Biomedical Central journal
9:371:1-8.
• WHO. 2006(a). Tuberculosis and air travel: Guidelines for
prevention and control. World Health Organization, Geneva:
1-30.
• WHO. 2009. Global tuberculosis control: a short update to the
2009 report. World Health Organization, Geneva:1-49
 References(Cont’d)
• Namibia. 2006. Ministry of Health and Social Services.
National Guidelines for the Management of TB, 2nd edition.
• Namibia. 2008a. Ministry of Health and Social Services.
Demographic and Health Survey Report 2006/7.
• OLAYINKA AYOBAMI AIYEGORO; (Nov-2016) DETERMINANTS
OF ADHERENCE TO TUBERCULOSIS THERAPY AMONG
PATIENTS RECEIVING DIRECTLY OBSERVED TREATMENT FROM
A DISTRICT HOSPITAL IN PRETORIA, SOUTH AFRICA
• Rieder, L. H. 2002. Interventions for tuberculosis control and
elimination. International Union Against Tuberculosis and
Lung Diseases.
Thank You!