Adherence to Multidrug Resistant Tuberculosis Treatment and Case Management in Chongqing, China - A Mixed Method Research Study

Abstract

Aim: This paper evaluated the treatment adherence for multidrug-resistant tuberculosis (MDR-TB) and MDR-TB case management (MTCM) in Chongqing, China in order to identify factors associated with poor treatment adherence and case management.

Methods: Surveys with 132 MDR-TB patients and six in-depth interviews with health care workers (HCWs) from primary health centers (PHC), doctors from MDR-TB designated hospitals and MDR-TB patients were conducted. Surveys collected demographic and socio-economic characteristics, as well as factors associated with treatment and case management. In-depth interviews gathered information on treatment and case management experience and adherence behaviors.

Results: Patient surveys found the two main reasons for poor adherence were negative side-effects from the treatment and busy work schedules. In-depth interviews with key stakeholders found that self-perceived symptom improvement, negative side-effects from treatment and financial difficulties were the main reasons for poor adherence. MDR-TB patients from urban areas, who were unmarried, were female, had migrant status, and whose treatments were supervised by health care workers from primary health clinics, had poorer treatment adherence (P<0.05). Among the MDR-TB patients surveyed, 86.7% received any type of MTCM in general (received any kind of MTCM from HCWs in PHC, MDR-TB designated hospital and centers of disease control/TB dispensaries and 62.50% received MTCM from HCWs in PHC sectors). Patients from suburban areas were more likely to receive both MTCM in general (OR=6.70) and MTCM from HCWs in MDR-TB designated hospitals (OR=2.77), but female patients (OR=0.26) were less likely to receive MTCM from HCWs in PHC sectors, and patients who were not educated about MTCM by TB doctors in designated hospitals were less likely to receive MTCM in general (OR=0.14). Patients who had not been hospitalized were less likely to receive MTCM from HCWs in MDR-TB designated hospitals (OR=0.21).

Conclusion: Stronger MTCM by HCWs in PHC sectors would improve treatment adherence among MDR-TB patients. Community-based patient-centered models of MTCM in PHC sectors and the use of digital health technology could help to improve case management and thereby improve adherence.

Keywords: adherence behaviors; management; multi-drug-resistant tuberculosis; treatment.

Figure 1

Integrated model for MDR-TB patients. This figure presents the integrated model of MDR-TB control. MDR-TB designated hospitals provide diagnosis and treatment and inpatient MTCM for MDR-TB patients. Centers for Disease Control and Prevention (CDCs) provide planning, assessment and case management related to MDR-TB control. Outpatient MTCM is mainly provided by health care workers (HCWs) in PHC sectors, including community health centres (CHCs) in urban areas as well as township hospital centres (THCs) and village clinics in rural areas.

Figure 2

Status of MDR-TB case management. This figure presents the type of provider, frequency of case management contact and methods of MDR-TB case management (MTCM) by HCWs from PHC sectors, MDR-TB designated hospitals or county CDCs (TB dispensaries). (A) presents the percentage of MDR-TB patients who received MTCM from CDC (TB dispensaries), MDR-TB designated hospitals and PHC sectors. (B) presents the percentage of MDR-TB patients who received different frequencies of MTCM from HCWs from PHC sectors, MDR-TB designated hospitals or county CDCs (TB dispensaries). (C) presents the percentage of MDR-TB patients who received MTCM through the different methods.

Figure 3

Status and reasons of poor adherence behaviors for MDR-TB patients. This figure presents the adherence to anti-TB treatment among MDR-TB patients (A), self-reported reasons for self-reduced drug intake (B), self-reported reasons for missed dosage (C), self-reported reasons for interrupted treatment (D), and self-reported reasons for missed follow-up sputum-exam (E).