1. Background 1
 § About 1/3 of world population infected with Tuberculosis (TB)
§ 25% of all avoidable deaths in developing countries due to TB
§ In Nepal, 45% of the population is infected with TB; of whom 60% in productive age group
§ 44,000 people develop active TB annually
with 20,000 having infectious pulmonary
form

2. Background 2 § Directly Observed Treatment Short-course
(DOTS) started in Nepal in 1996 and was implemented throughout the country by April 2001
§ However, still in 2001/2002, 6,000-8,000 people died from TB
§ Under DOTS, 8 months treatment schedule
is followed and anti-TB drugs are given free of charge
§ Non-adherence is a principal cause of treatment failure.

3. Objective
To analyse the association between socio-economic position and patients’ adherence to anti-TB treatment under DOTS

4. Setting:
§ Study conducted in Kaski, a western hilly district in Nepal
§ TB treatment under DOTS offered by the Regional TB Center (RTC), 2 Primary Health Centers (PHCs), 8 Health Posts (HPs), 3 Sub-health Posts (SHPs), etc
Population:
§ All sputum positive patients, whether they
completed their treatment (adherents)
or not (non-adherents)
§ From mid-July 1999 to mid-July 2001, totally 50 non-adherent and 309 adherent patients were
registered
Methods 1

5. Methods 2 Design: § Case-control study Data collection method:
§ Cases: patients who did not complete treatment
§ Controls: patients who completed treatment
Data collection method:
§ Face-to-face questionnaire based interviews
Socio-economic variables:
§ Gender, age, marital status, literacy, occupation, living area, caste, income, living conditions, travel cost to the TB treatment facility, and affordability of treatment

6. Methods 3
Analyses:
§ Relationship of all socio-economic risk factors with non-adherence (outcome) performed by
cross-tabulation
§ Significance of risk (OR) of becoming non- adherent were calculated by Chi-square and Chi- square trend tests
§ Means calculated by independent sample t-tests
§ Bivariate and multivariate analyses performed to identify factors associated with non-adherence

7. Table 1: Background characteristics of respondents

8. Table 2: Risk of nonadherence to anti-TB treatment by socioeconomic position estimated from multivariate logistic regression analysis (N=129)

9. Table 2: Risk of nonadherence to anti-TB treatment by socioeconomic position estimated from multivariate logistic regression analysis (N=129) (contd)

10. Conclusions & recommendations 1
§ Even in DOTS and with free drugs, low socio- economic position is an important risk factor for nonadherence , especially lack of cash in hand
§ Raises pertinent issues ”Are DOTS and free distribution of anti-TB drugs enough to make patient adherent towards their treatment?”
§ Considerations of indirect costs in addition to direct costs are important in National TB control pogrammes in poor countries

11. Conclusions & recommendations 2
§ Research on other aspects needed to get fuller understanding of the lack of success of the DOTS strategy, for example
n Norms and values in local community
n Health care providers’ attitudes, values and behaviour
n Meaning of treatment from patients’ own perspective