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

Figures & data

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.

Table 1 Demographic, Socio-Economic and Clinical Characteristics of MDR-TB Patients in Chongqing

Characteristics		No.	%
Age (n=132)	15–35	34	25.7
	36–55	57	43.2
	>55	41	31.1
Gender (n=132)	Male	84	63.6
	Female	48	36.4
Place of residence (n=132)	Urban area	56	42.4
	Suburban area	76	57.6
Resident status (n=132)	Migrants	6	4.5
	Resident	126	95.5
Marital status (n=132)	Married	83	62.9
	Divorced/widowed	21	15.9
	Unmarried	28	21.2
Education (n=132)	Primary and below	40	30.3
	Middle school	73	55.3
	College and above	19	14.4
Occupation (n=132)	Employed in enterprises/institutions/government	23	17.4
	Peasants/rural migrant workers	51	38.7
	Others (unstable work or no income)	58	43.9
Health insurance (n=132)	Urban Employee Basic Medical Insurance (UEBMI)	23	17.4
	Resident Basic Medical Insurance(RBMI)	108	81.8
	No medical insurance	1	0.8
Distance to the nearest drug-resistant designated hospital (n=132)	≤30 minutes on foot	4	3.0
	≤2 hours by bus	49	37.1
	> 2 hours by bus(round trip in one day)	49	37.1
	>2 hours by bus (overnight)	30	22.8
Received MDR-TB treatment before (n=132)	Yes	128	97.0
	No	4	3.0
Received free TB treatment (n=117) *	Yes	68	58.1
	No	49	41.9
Treatment delay (n=128) *	<3 day	89	69.5
	3–30 day	21	16.4
	>30 day	18	14.1

Note: *Missing data were excluded.

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).

Table 2 Multivariate Logistic Regression Analysis of MTCM

Categories	Received MTCM in General	Received MTCM from HCWs from CHCs/THCs/Village	Received MTCM from HCWs from MDR-TB Designated Hospital
	OR(95% CI)	OR(95% CI)	OR(95% CI)
Age
15–35	1	1	1
36–55	2.31(0.64–8.31)	2.22(0.75–6.59)	0.38(0.14–1.08)
>55	1.38(0.38–4.98)	0.89(0.28–2.89)	0.49(0.16–1.52)
Gender
Male	1	1	1
Female	1.50(0.47–4.80)	0.26(0.12–0.63) *	0.70(0.31–1.59)
Health insurance
Urban Employee Basic Medical Insurance (UEBMI)	1	–	–
Resident Basic Medical Insurance(RBMI)	1.85(0.43–7.97)	–	–
Marital status
Married	–	1	–
Divorced/widowed	–	2.20(0.74–6.57	–
Unmarried	–	0.67(0.17–2.56)	–
Hospitalization
Yes	1	–	1
No	0.44(0.11–1.84)	–	0.21(0.07–0.63) *
Place of residence
Urban area	1	–	1
Suburban area	6.70(1.52–29.55) *	–	2.77(1.19–6.43) *
Educated about MTCM by HCWs in PHC sectors
Yes	1	–	–
No	0.14(0.03–0.74) *	–	–

Notes: *P<0.05. “–” refers to this variable was not included in the logistic model for this independent variable.

Abbreviations: OR, odds ratio; CI, confidence interval; MDR-TB, multidrug-resistant tuberculosis; PHC, primary health care; MCTM, MDR-TB case management; HCWs, health care workers.

Table 3 Multivariate Logistic Regression Analysis of Poor Adherence Behaviors

Categories	Non-Adherence	Self-Reduced Drug Intake	Missed Dosage	Interrupted Treatment	Missed Follow-Up Sputum-Exam
	OR(95% CI)	OR(95% CI)	OR(95% CI)	OR(95% CI)	OR(95% CI)
Age
15–35	1	1	1	1	1
36–55	0.46(0.18–1.14)	0.48(0.04–6.54)	0.52(0.22–1.25)	1.03(0.34–3.14)	0.72(0.25–2.06)
>55	0.86(0.31–2.42)	6.54(0.87–49.40)	0.77(0.30–1.98)	1.91(0.61–5.97)	0.84(0.28–2.55)
Gender
Male	1	1	1	1	1
Female	0.76(0.35–1.64)	1.10(0.50–6.61)	0.68(0.31–1.47)	0.74(0.29–1.90)	2.68 (1.09–6.60)*
Place of residence
Urban area	1	–	–	–	–
Suburban area	0.37(0.17–0.81)*	–	–	–	–
Resident status
Resident	–	1	–	–	–
Migrants	–	15.31(1.54–152.23)*	–	–	–
Marital status
Unmarried	–	–	1	–	–
Married	–	–	0.29(0.11–0.73)*	–	–
Divorced/widowed	–	–	0.41(0.12–1.39)	–	–
Received any supervision
No	–	1	–	–	–
Yes	–	0.22(0.05–0.99)*	–	–	–
Received MTCM from HCWs from CHCs/THCs/village
No	–	–	–	1	–
Yes	–	–	–	3.84(1.05–14.09)*	–

Notes: *P<0.05. “–” refers to this variable was not included in the logistic model for this independent variable.

Abbreviations: OR, odds ratio; CI, confidence interval; MCTM, MDR-TB case management.

Table 4 Qualitative Results About MDR-TB Treatment Adherence and Management

Themes	Results	Quotation
Patients’ adherence with MDR-TB treatment	All MDR-TB patients, HCWs from PHC sectors and MDR-TB designated hospitals reported poor adherence among MDR-TB patients.	“ I stopped taking drugs after 7 or 8 months … too much side-effects caused me unable to adhere … cough disappeared, so I think I was cured”(MDR-TB patients)
		“They cannot adherence with the treatment” (HCW from PHC sector)
		“About 10% patients cannot adherence with treatment” (HCW from designated hospital)
Reasons for non-adherence with MDR-TB treatment	The most often mentioned reasons for interrupt treatment by the MDR-TB patients, HCWs from PHC sectors and MDR-TB designated hospitals were improvements in symptoms and side-effects of drugs. Financial difficulty was also the reason though there was special health insurance of reimbursement of 90% treatment fee or 50,000 RMB per year. Individual HCWs from MDR-TB designated hospitals reported that patients had poor adherence because of busy with work.	… I stopped drugs after feeling better, … my hands were so swelling, painful, trembling, … can’t eat drugs anymore … too much side-effects … I don’t have money for follow-up examinations, … I can only borrow money from my daughter-in-law (MDR-TB Patient)
		“ … there is one MDR-TB patient with liver cancer and drug-related liver damage, he almost stopped treatment now” (HCW from PHC sector)
		“ … but major symptoms disappeared, they believed they are cured” (HCW from designated hospital)
		“ … some patients interrupted treatment due to busy work ….some patients had financial difficult though there is the special health insurance of reimbursement of 90% treatment fee or 50,000 RMB for MDR-TB patients in Chongqing, some patients had multiple and server side-effects and could not adherence with treatment”(HCW from designated hospital)
HCWs behaviours related to MTCM	All patients stated they received management by telephone from HCWs in PHC sectors and they mainly received health education on MDR-TB knowledge from HCW from MDR-TB designated hospitals instead of HCWs from PHC sectors. Though all HCWs in PHC sectors mentioned it is difficult to manage MDR-TB patients comparing with drug-sensitive TB patients, they delivered MDR-TB patients management according to guideline. And they provided health education and psychological counseling during home visits and telephone calls. All HCW from MDR-TB designated hospitals claimed that they would call patients to take follow-up examinations and pick medicines, and they also provided health education to them.	“ … HCW from XX designed hospital told me to take medicine one to two years at least … pick drugs regularly … during the treatment period, only received telephone calls from HCWs in PHC sectors once per month and asked me whether I felt better and kept taking drugs”(MDR-TB patient) “ … HCW from designated hospital never called or home visited me … HCWs from PHC sectors called me … this disease will not cure if I interrupt the treatment … they did not say about side-effect … HCW from PHC sector noticed me to get blood test and liver function test … called me and asked why I did not take follow up”(MDR-TB patient) “ … we connected with patient, and conducted home visit … often called them, mainly for their medicine taking … and their psychological conditions, to communicated with them … every month … most were phone calls … for MDR-TB patients, three times per month during the first six month … once per month for continues phase … I provide health education to them during home visit, and their families, e.g. dangerous of transmission … regular drug taking … open windows at home … close contacts screening … some patient have pressures, I would provide more psychologically communications”(HCW from PHC sector) “ … we also provide health education when they consulted in our hospital, eg, eating nutritionally … preventing diseases transmission, contacts screening”(HCW from designated hospital)
MDR-TB patients’ willingness to receive management by HCWs in PHC sectors	One MDR-TB patient expressed strong willingness to receive management from HCWs in PHC sectors, but another patient thought HCWs cannot help him.	“It is good to have HCW in PHC sectors provide management to me” (MDR-TB patient)
	All HCWs in PHC sectors mentioned that most patients cooperated with management, and HCW from MDR-TB designated hospitals mentioned MDR-TB patients trust more HCWs from PHC sectors and possibly receive management from them.	“The HCW in PHC sectors can only ask me to know whether I felt better, can’t help me more”(MDR-TB patient)
	But HCWs from both PHC sectors and MDR-TB designated hospitals reported some patients, especially the youths, do not like to receive their management because of social stigma.	“ … the patients didn’t hope their friends know they are having TB … … so they would not let you go to their home … they even didn’t pick our calls … ” (HCW from PHC sector)
		“ … most MDR-TB patients cooperated well, they are old people … but some patients are unwilling to receive management … especially the youths, they wouldn’t like me visit their home, … He wouldn’t open the door even I visited his home three times” (HCW from PHC sector)
		“Generally speaking, patients would engaged more communications with HCWs from PHC sectors, patients would more likely to trust them … ”(HCW from designated hospital)
		“There was one student, he is unwilling to receive home visit from the HCWs from PHC sectors … he really dislike our management … ”(HCW from designated hospital)

Abbreviations: TB, tuberculosis; MDR-TB, multidrug-resistant tuberculosis; PHC, primary health care; HCWs, health care workers; MCTM, MDR-TB case management.