Adherence to tuberculosis (TB) treatment can be improved by supervision of pill-taking, known as directly observed treatment (DOT). In community-based TB treatment, patients are supervised taking their medication at home by local volunteers. Their work can produce major changes in mortality and health status, but what motivates these volunteers?

Researchers from the UK University of Oxford and South Africa's Gordonia TB Hospital explored factors that motivate lay volunteers to join TB control programmes in the Northern Cape province, a high burden, but resource-limited setting. They conducted three focus group discussions, reviewed the records of 347 volunteers and interviewed 135 volunteers.

The TB incidence rate in Northern Cape province is 521 cases per 100,000 population. The province adopted the WHO-recommended DOTS strategy in 1997. TB patients can choose whether to report to the clinic five days a week to receive treatment from clinic staff or to be supervised at home by community members. Up to one-third choose home treatment.

Unpaid volunteers receive four days of training. They are taught to dispense anti-TB drugs to patients five days a week for the whole duration of treatment. They also record each intake of pills, follow up absent patients, remind patients of clinic appointments and refer patients with other problems to the relevant services. TB treatment for new patients lasts for six months and re-treatment lasts eight months.

The study showed that:

• Over 90 percent of volunteers are female.
• 70 percent are younger that 45 and three-quarters do not have any formal employment.
• 90 percent say they would like to receive more recognition from the health services and continued support after their initial training.

Factors reported to motivate volunteers include:

• altruism - especially those patients who have been patients themselves or know people affected by the disease
• filling in spare time - particularly for younger volunteers
• gaining work experience - the attraction of getting good references and contacts
• the novelty factor - community participation in TB control in the province is relatively new.

Volunteers started to leave as soon as the novelty wore off and they realised they had to support patients for a long period of time without pay. Of the dropouts, more than 75 percent of them had lost interest, got better jobs or relocated to other areas in search of paid work.

The majority of volunteers are young, reasonably educated but unemployed. This threatens the sustainability of the community-based programme. This will become even more important if TB and HIV programmes are integrated, as recommended by WHO, and the workload of volunteers increases.

TB control programmes in high burden settings should explore the option of providing monetary incentives to volunteers to reduce attrition rates. They should also consider other forms of recognition, such as awarding post-training certificates, and non-monetary incentives, like t-shirts and badges for volunteers.

Source(s):
'What motivates lay volunteers in high burden but resource-limited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa', International Journal of Tuberculosis and Lung Disease 6 (2): 104-110, by S. Kironde and S. Klaasen, 2002
Related source: 'Community participation in primary health care (PHC) programmes: lessons from tuberculosis treatment delivery in South Africa', African Health Sciences 2 (1): 16-23, by S. Kironde and M. Kahirimbanyi, 2002

Funded by: Sir Halley Stewart Trust; UK Department for International Development

id21 Research Highlight: 08 May 2002

Further Information:
Samson Kironde
7 Sandown Hills
103 Katherine Road
Sandown, Sandton 2196
South Africa

Tel: +27 (0)82 883 5450
Fax: +27 (0)11 506 9009
Contact the contributor: skironde@hotmail.com

University of Oxford

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