Factors associated with tuberculosis treatment default and completion at the Effia-Nkwanta Regional Hospital in Ghana

Abstract
The level of defaulting from treatment among tuberculosis (TB) patients at the Effia-Nkwanta Regional Hospital between January 2000 and December 2001 was 13.9%. This study was therefore designed to assess factors associated with TB treatment default and completion at the hospital. The initial part of the study consisted of three separate focus group discussions for health workers, defaulters and non-defaulters. The information collected was used to design a questionnaire that was administered to defaulters and non-defaulters selected from the Institutional TB Register. Univariate logistic regression analysis was performed to identify significant factors associated with treatment default. Statistical significance was taken as P < 0.05. Default from treatment was significantly associated with income per month ( P = 0.03), ability to afford supplementary drugs ( P = 0.008), availability of social support ( P = 0.005) and problems relating with others while on treatment ( P = 0.01). A cordial relationship between patients and health staff was the main motivating factor for completion of treatment, whilst financial difficulty was the main reason for defaulting from treatment. Determination of the characteristics found to be associated with defaulting in this study among TB patients at the start of treatment may be helpful in improving compliance among patients registered for treatment at the hospital. Keywords Tuberculosis Defaulter Treatment Ghana 1 Introduction The greatest problem facing tuberculosis (TB) control programmes all over the world is how to ensure that all patients complete the prescribed duration of treatment ( Styblo, 1988 ). Premature interruption of treatment presents a problem for patients, their families and those who care for them, as well as those responsible for the TB programme ( WHO, 2003 ). Compliance with effective treatment rapidly, within a couple of weeks, makes a previously infectious patient non-infectious ( Dick et al., 1996 ). Non-compliance with treatment, on other hand, may lead to persistence and resurgence of TB and is regarded as the chief cause of relapse and drug resistance ( Comolet et al., 1998 ). Non-compliance also results in increased transmission rates of the tubercle bacilli, morbidity and cost to the TB control programmes ( Johansson et al., 1999 ). A defaulter is defined as a patient who has interrupted treatment for 2 months or longer ( WHO, 2003 ). A review of data on defaulting among TB patients at the Effia-Nkwanta Regional (ENR) Hospital between January 2000 and December 2001 revealed a defaulter rate of 13.9%. The probability of a patient remaining on treatment at 2 months and 5 months after starting treatment was 57.8% and 3.6%, respectively, with a mean defaulting time of 3.4 months. Default from treatment was found to be significantly associated with male sex, smear positivity and living in communities far from the treatment centre ( Dodor, 2004 ). This study was therefore designed to assess factors associated with treatment default and completion in patients registered and treated for TB at the hospital. 2 Subjects and methods 2.1 Study setting The study was conducted at the ENR Hospital, which is located at Sekondi-Takoradi, the capital and third largest city of the Western Region of Ghana. The ENR Hospital has a unit called the Communicable Diseases Unit (CDU) where all TB patients receive treatment. It also serves as the referral unit for complicated cases of TB seen in other hospitals within the region. 2.2 TB diagnosis and treatment at the ENR Hospital Cases of TB are diagnosed among patients reporting to the Outpatient Department of the hospital. Individuals who presented with cough lasting for 3 weeks or more are made to undergo sputum smear microscopy and chest radiography examinations. Those found to be suffering from TB are then referred to the CDU where they are registered and started on TB treatment. During the intensive phase of treatment, patients who live at communities far away from the CDU are supplied with their drugs and then referred to a health facility nearer to their normal place of residence for direct observation of treatment (DOT) on a daily basis; patients living near the CDU come there every morning for DOT. Approximately 90% of patients are managed daily on this ambulatory basis for the entire intensive phase. However, patients who are severely ill or have other medical complications that will not permit ambulatory treatment are admitted to the CDU for treatment. The continuation phase of treatment is unsupervised, so all patients are seen at the CDU every month on an ambulatory basis irrespective of where DOT was received during the intensive phase. This enables review of progress of treatment to be made as well as the supply of medications for the following month. The treatment regimens and outcomes used throughout Ghana are those recommended by the WHO. Briefly, these treatment regimens are as follows. New patients with sputum smear-positive pulmonary tuberculosis (PTB), severely ill smear-negative PTB and extrapulmonary tuberculosis (EPTB) were given an 8-month regimen consisting of 2 months of daily supervised streptomycin, rifampicin, isoniazid and pyrazinamide in hospital followed by 6 months of daily unsupervised isoniazid and thioacetazone (2SRHZ/6HT). New patients with smear-negative PTB and less serious forms of EPTB were given a 12-month regimen consisting of 2 months of daily supervised streptomycin, isoniazid and thioacetazone in hospital followed by 10 months of daily unsupervised isoniazid and thioacetazone (2SHT/10HT). Previously-treated TB patients (relapse, treatment failure and treatment after default) were given an 8-month regimen consisting of 3 months of daily supervised rifampicin, isoniazid, pyrazinamide and ethambutol, supplemented by streptomycin during the first 2 months in hospital followed by 5 months of unsupervised thrice weekly rifampicin, isoniazid and ethambutol...