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:

• multi-drug-resistant tuberculosis
• management
• treatment
• adherence behaviors

Acknowledgments

The authors would like to thank all the patients, TB doctors and healthcare workers who participated in this study.

Abbreviations

CDC, centers of disease control; CHCs, Community Health Centers; CPHMC, Chongqing Public Health Medical Center; CIS-DCP, China Information System for Disease Control and Prevention; HCWs, Health Care Workers; INH, Isoniazid; MDR-TB, Multidrug-resistant Tuberculosis; MTCM, MDR-TB Case Management; NTP, National Tuberculosis Control Programme; PHC, Primary Health Care; RFP, Rifampicin; RR-TB, Rifampicin-resistant Tuberculosis; TB, Tuberculosis; THCs, Township Hospital Centers; WHO, World Health Organization; XDR-TB, Extensively Drug-resistant Tuberculosis.

Data Sharing Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the study.

Ethical Approval and Consent to Participate

The project was approved by the Institutional Review Board of Army Medical University, Chongqing, China, and was conducted in accordance with the Declaration of Helsinki. All participants gave their written informed consent to participate, and parental consent was obtained for participants under the age of 18.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.