Tuberculosis is one of the most common killers in developing countries and the numbers of cases are continuing to grow. TB programmes have emphasised directly observed treatment where someone watches while patients take their medicine, in order to prevent recurrence of the disease. How effective has the component of direct observation been in Pakistan?

DOTS (directly observed treatment, short course) is the brand name of the World Health Organisation TB strategy which aims to improve overall care of TB patients including diagnosis, treatment, monitoring the outcome, the supply of drugs, and direct observation.

In Pakistan, as elsewhere, implementing the TB strategy improved cure rates. The Association for Social Development, Islamabad, together with the University of Leeds, UK, carried out a study to assess how useful the direct observation of treatment (DOT) component has been in encouraging patients to adhere to therapy.

Over a period of eight months 500 patients were treated for TB in three areas of Pakistan. In a randomised controlled trial, one group of patients was observed by health workers on a daily basis for the first two months, either at home or at the clinic. The second group of patients were observed by a family member as they took the medicine, while the third group took the drugs without external observation. All the patients had otherwise the same diagnosis, treatment, tests and follow up.

The trial showed no significant difference between the groups - no additional benefit from the DOT component. An economic study had showed a high cost of daily visits for DOT by health workers may have contributed to patients defaulting from TB treatment. The researchers used a social study to ask patients about their experience of DOT.

The social study found that 40 percent of patients were not able to follow the form of DOT they were allocated to. Related findings included:

• More than half of the patients in the first group were unable to attend the clinic every day. They collected the drugs weekly and took the medicine themselves.
• Patients who should have been visited at home were expected to walk to the house of the community health worker, despite being unwell. The community health worker would often then not be at home.
• When family members were away, the patients in the second group had to administer their own treatment.
• Family members often intervened to make sure patients in the third group took their medicine on time.
• Patients found it difficult to attend the clinic due to costly and limited transport. This was especially the case for those asked to attend health facilities daily for DOT.

The study helped explain why there was no additional benefit from the DOT part of the TB strategy.

Interestingly, the cure rate for women (71 percent) was much higher than for men (50 percent).  Women were more motivated to recover because they were concerned about their duties in the home or they did not want ill health to affect their marriage prospects. Men find it particularly difficult to daily attend a clinic for DOT because they have to take time out of paid employment.

The study recommends:

• instead of 'policing’ tablet taking, the emphasis should be on treatment support from someone who is reliable, accessible and acceptable to the patient
• providing more health education, so that patients understand the importance of completing the treatment
• clinics should have more flexible opening hours
• patients should, where possible, be helped with travel costs.

Source(s):
‘Tuberculosis patient adherence to direct observation: results of a social study in Pakistan’, Health Policy and Planning 20(6): 354-263, by A. Khan, J. Walley and S. Witter, 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 16 March 2006

Further Information:
Sophie Witter
IMMPACT
University of Aberdeen
Aberdeen AB24 3FX
UK

Tel: +44 (0) 1224 273500
Contact the contributor: sophiewitter@blueyonder.co.uk

Nuffield Centre for Centre for International Health and Development, University of Leeds, UK

Other related links:
'Is watching tablet taking helpful? TB DOTS and costs in Pakistan'

'Medication and education: tackling TB in Pakistan'

'Join the DOTS? Direct observation of TB treatment in Pakistan'

'Care in the community? TB treatment in rural Swaziland'

'A public-private partnership: fighting tuberculosis in South Asia'

'Keep it in the family: supporting TB treatment in Swaziland'

'DOT topic – expanding the debate on directly observed tuberculosis treatment'