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Non-adherence to tuberculosis treatment in the eastern Tarai of Nepal.

SETTING
Tarai districts, eastern Nepal.


OBJECTIVES
To identify potential methods of increasing adherence to tuberculosis (TB) treatment by determining factors that patients felt influenced adherence.


METHODS
New pulmonary TB patients registered from July to November 1998 with an outcome of non-adherence to treatment (NA) were identified from District TB Registers, traced and interviewed using a semi-structured questionnaire. An equivalent number of adherent (A) patients were interviewed.


RESULTS
Of 81 NA patients traced, 30 were interviewed, 16 had been incorrectly classified, age was incorrectly recorded in four, 13 had migrated and 18 were not found. The groups were similar in demographics, type and knowledge of TB. More A patients knew their diagnosis (P = 0.07) and reported haemoptysis as an initial symptom (P = 0.03). NA patients had longer travel to a health facility (P < 0.001), and fewer had been informed by health care workers (HCW) about the consequences of not completing treatment. The most common reasons given for stopping treatment were side-effects, HCWs' mistakes or behaviour, and health service failure. Desire for cure and knowledge that TB was curable were most the important reasons for completing treatment.


CONCLUSION
Non-adherence seemed related to treatment delivery failures. The health system needs strengthening in Nepal. Intensified HCW training and supervision, better health education for patients and families, more flexibility for treatment supervisors, adequate supplies for treatment centres and decentralisation of treatment delivery to the lowest health service level practicable are urgently needed.