Translate this page into:
The effect of telephone follow-up and training on treatment adherence in tuberculosis patients and contacts: A randomized controlled study
Correspondence to: SEMA AYTAÇ; aytac.sema27@gmail.com
[To cite: Aytaç S, Ovayolu Ö. The effect of telephone follow-up and training on treatment adherence in tuberculosis patients and contacts: A randomized controlled study. Natl Med J India 2025;38:69–77. DOI: 10.25259/ NMJI_1061_2022]
Abstract
Background
We evaluated the effect of 6 months of regular training, tele-monitoring and daily text message to remind medication intake on treatment adherence in tuberculosis (TB) patients and their contacts.
Methods
This randomized, controlled study with pre- test and post-test design was conducted with the following groups: TB Intervention, TB control, contacted intervention and contacted control group, a total of 66 patients and 87 contacted people. The data of study were collected with ‘Patient and Contact Question Form’, Tuberculosis Adherence Determination Questionnaire (TADQ) and ‘Morisky 8-Item Adherence to Drug Questionnaire’ (MMAS-8).
Results
TADQ scores of the TB intervention group in the beginning, 1st, 3rd and 6th months were 80.4 (7.9), 117.8 (6.3), 137.7 (7.5), 143.2 (4.5), respectively, and TADQ scores of the TB control group in the beginning, 1st, 3rd and 6th months were 88.1 (7.1), 84.5 (9.8), 75.9 (7.9), 65.2 (9.2), respectively. MMAS-8 scores of the contacted intervention group in the beginning, 1st, 3rd and 6th months were 3.6 (1.3), 5.5 (0.7), 7.2 (0.8) and 7.7 (0.7), and those of the control group were 5.7 (1.4), 4.3 (1.4), 1.8 (1.5) and 0.7 (1.4), respectively.
Conclusion
As a result of 6 months of regular training, tele-monitoring and daily text message, adherence of the patients to TB treatment increased, and the adherence of the contacted people to the medication increased. Nurses should take an active role in the management of TB, determine the patients who do not use drugs correctly in the early period and apply the required interventions as soon as possible to improve treatment adherence of TB patients and contacts.
INTRODUCTION
It is estimated that approximately 10 million people are diagnosed with Tuberculosis (TB) every year in the world and 1.7 billion people are infected by Mycobacterium tuberculosis (MTB) and at risk for development of the disease.1 A ‘contact person’ is defined as someone who shares the same environment as a patient suffering from contagious TB and is exposed to MTB bacilli.1
The aim of the TB control and prevention programmes is to identify active TB patients for treatment and also to screen contact persons for latent TB and active cases amongst them. Current guidelines emphasize the importance of screening all the contacts of patients with pulmonary TB for prophylaxis for community healthcare.2,3 Thus, it is important to perform contact screening of the relatives of TB patients.4 Individuals on treatment must receive medicines regularly for at least 6 months.3 Adherence to this period is important for the success of the treatment. However, it has been reported that the rate of non-adherence to treatment varies between 20% and 80% and non-adherence is the most serious barrier for control of the disease. İncomplete treatment may result in long- lasting infection, drug resistance, relapse and death.5,6
It has been shown that in individuals with chronic diseases, tele-follow-up is effective in promoting self-care and cognitive- social adaptation among patients.7 It has also been reported that some problems in the treatment of TB patients such as the interruption of treatment, forgetting medication (24.5%), side- effects of drugs (23.3%), symptomatic recovery (19.5%),8 failure to know the necessity of completing the life cycle of drugs, and not receiving adequate training may be managed more effectively by tele-follow-up.9
Nurses are involved in all the processes of protecting and promoting the health of individuals, families and society, and in their recovery in case of disease.10 It has been proposed that tele-mobile nursing services are a cost-effective method since it decreases the hospitalization rate and period of TB patients.11 Accordingly, we assessed the effect of 6 months of regular training, tele-monitoring and daily text message to remind medication intake, provided by nurses for TB patients and contacts, on medication adherence.
METHODS
Setting and sample
This study was a randomized, controlled trial of patients receiving treatment in a TB dispensary, located in the southeast of Turkey, between July 2018 and July 2019. The sample size of the study was determined according to the result of the power analysis by using G power 3.1. The minimum sample size required for the difference to be significant was determined to be at least 21 patients in each group (α = 0.05, 1–β = 0.80, effect size = 0.80).
Inclusion and exclusion criteria
Subjects were recruited as patients if they were adults, literate, diagnosed with pulmonary TB and started on treatment not more than 15 days earlier and willing to participate and able to communicate using a telephone. Illiterate individuals and those with multi-drug resistance were excluded.3
Contacts were adults, literate, fulfilled the criteria of being a household contact of a pulmonary TB patient and were receiving isoniazid (INH) treatment, willing to participate and able to communicate using a telephone.
Data collection
Patients data was collected using a questionnaire and the TB Adherence Determination Scale (TADQ). The patient questionnaire consisted of 35 questions, prepared based on literature review, for collecting socio-demographic and disease- related characteristics.12–15 TADQ was developed by DiMatteo et al., to examine adherence to cancer programmes and it was adapted by McDonnell for TB patients.17 It is a 5-point Likert scale and higher scores signify improved adherence. Cronbach’s alpha values of TADQ were calculated to be 0.712 at the beginning, 0.889 in the 1st month, 0.916 in the 3rd month and 0.921 in the 6th month. 13
Contacts data was collected using a 26-point form, composed of questions about their socio-demographic status and their willingness to participate, created from literature review.3,16 Contacts also completed the Morisky-8 item medication adherence scale (MMAS-8), developed and validated by Morisky et al.18-20 The MMAS-8 is a diagnostic adherence assessment instrument, consisting of 8 items. The range of the scale is from 0 to 8 with 0 indicating low adherence and 8 showing high adherence. A categorical frequency distributes the scale into the following three parts: Low adherence <6, medium adherence 6 to<8 and a score of high adherence being 8.
Randomization
The patients who attended the dispensary for treatment and their contacts were informed about the aim and scope of the study and were randomized into the intervention and control groups. Randomization was done using computer-generated random numbers (Statistical Package for the Social Sciences version 20 software) by a statistician who had no contact with the participants and did not participate in the study. All patients participating in the study were blinded during the randomization process but the researchers were not blinded due to the nature of the intervention.
TB patients and contacts were divided into intervention and control groups. To prevent the contacts from being affected by the education and telephone monitoring being provided to the TB patients, all contacts of patients in the TB patient intervention group were included in the contact intervention group. Four groups were formed: TB intervention, TB control, Contact intervention and Contact control.
The interviews were performed using the face-to-face interview technique in the outpatient clinic. In the first interview, the questionnaire was administered to all four groups. Subsequently, the following steps were followed:
TB intervention group
Patients were reminded to take the drug through patient training, telephone follow-up and daily messages on telephone (short message service, SMS) in addition to directly observed treatment (DOT).
Patient training. Training was provided using a booklet prepared by the researchers after literature review and expert opinion.1,3,5 The training was repeated using face-to-face interview 2 weeks after the first session. It was continued for 6 months by conducting face-to-face interviews once a month. The TB training booklet addressed the following questions:
What is TB?
How is TB microbe transmitted?
How can TB contagion be prevented?
What are the risk factors for the development of TB disease?
In which organs does TB disease occur?
What are the symptoms of TB disease?
How is TB disease diagnosed?
How is TB disease treated?
What are the side-effects of TB medicines?
The training was delivered by the first author who had received ‘TB Health Workers TB Control Training’. Any questions asked by the patients were answered in accordance with the explanations in the training booklet. Training in the first meeting took approximately 25–30 minutes, while each of the next interviews took approximately 10–15 minutes. Individual training was provided to patient and contacts.
Telephone follow-up
A telephonic interview was performed every 15 days where they were asked ‘How do you feel? Do you take your medicine according to the recommendations’? The questions of the patients, if any, were answered and the problems they faced regarding the treatment adherence were addressed. The last interview was conducted face-to-face at the dispensary. Telephone follow-up took approximately 5–10 minutes and continued for 6 months.
An SMS was sent daily for 6 months as a reminder stating ‘Please, don’t forget to take your TB drugs’.
TADQ was administered at the beginning of the treatment and in the 1st, 3rd and 6th months.
TB control group
These patients received the standard follow-up procedures. They were informed about TB and the drugs they would use. They were advised by the doctor and nurse to provide sputum samples each month in the dispensary and have a chest x-ray once every 2 months. Those who did not come for follow-up were called to come to the dispensary and the TB drugs were sent monthly to their family doctor. TADQ was admistered to this group at the beginning of the treatment and in the 1st, 3rd and 6th months.
Contact intervention group
In this group, the subjects were provided training, telephone follow-up and daily SMS.
Contact training. Training was provided using a booklet developed by the researchers after literature review and expert opinion.2–4 The topics of the TB contact training booklet were:
What is TB and its cause?
How is the bacteria causing TB transmitted?
What does it mean to be in contact with a TB patient?
Who is TB contact?
What is the incidence of TB patients and contacts?
How is contact screening done in TB dispensary?
Who is given preventive drug therapy?
What is the dose and duration of preventive drug treatment?
The training was provided by the first author who had received ‘TB Health Workers TB control Training’. Contact training in the meeting took approximately 25–30 minutes. Individual training was provided.
Telephone follow-up of contacts. Telephone interviews were conducted every month asking questions such as ‘How do you feel today, did you receive the preventive medication treatment as is recommended, anything else you want to ask?’ etc. Telephone follow-up took approximately 5–10 minitues and continued for 6 months.
The SMS ‘Don’t forget to get your preventive medication’ was sent every day for 6 months.
The MMAS-8 was repeated at the beginning of the treatment and in the 1st, 3rd and 6th months.
Contact control group
The standard follow-up was performed in this group. The importance of the preventive medication was informed. They were also informed that they should use medication for 6 months to prevent the development of TB. MMAS-8 was repeated at the beginning of the treatment and in the 1st, 3rd and 6th months.
Ethical considerations
Before the study, permissions were received from the ethics committee (Decision No: 2018/84), Provincial Directorate of Health, and patients and contacts were informed about the aim of the study and the content of the forms.
Data assessment
Normal distribution of the data was tested using Shapiro–Wilk test. Mann–Whitney U test was used for the comparison of the scale scores without normal distribution in two independent groups and Kruskal–Wallis and Dunn’s multiple comparison tests were used in the comparison in three or more independent groups. Freidman test was applied in the assessment of the change of the scale scores obtained in several periods and the period causing the difference was tested by Dunn’s multiple comparison test and the relations between the categorical variables were tested by Chi- square test. p<0.05 was considered to be statistically significant.
RESULTS
Socio-demographic characteristics of participants
The study included 66 TB patients in the intervention (n=32) and control groups (n=34) respectively and 87 contacts in the intervention (n=41) and control groups (n=46) (Fig 1). The mean (SD) age of the patients in the TB intervention and control groups was 40.1 (15.6) years and 45.2 (16.9) years, respectively, and the groups had a homogeneous distribution in terms of the socio-demographic characteristics (Table I). 15 TB patients and 3 contacts were excluded since they were transferred to another dispensary and they died.
- Flowchart of the study participants TB tuberculosis
| Characteristic | Tuberculosis group | Contact group | |||||
|---|---|---|---|---|---|---|---|
| Intervention | Control | p value | Intervention | Control | p value | ||
| n=32 (%) | n=34 (%) | n=41 (%) | n=46 (%) | ||||
| Gender | |||||||
| Male | 22 (68.8) | 18 (52.9) | 0.19 | 14 (34.1) | 25 (54.3) | 0.06 | |
| Female | 10 (31.2) | 16 (47.1) | 27 (65.9) | 21 (45.7) | |||
| Age group (in years) | |||||||
| 18–34 | 14 (43.8) | 13 (38.2) | 0.49 | 18–29 | 14 (34.3) | 14 (30.4) | 0.89 |
| 35–53 | 10 (31.2) | 8 (23.6) | 30–41 | 10 (24.2) | 13 (28.3) | ||
| ≥54 | 8 (25.0) | 13 (38.2) | ≥42 | 17 (41.5) | 19 (41.3) | ||
| Educational status | |||||||
| Literate | 3 (9.4) | 11 (32.4) | 0.71 | 7 (17.1) | 11 (23.9) | 0.23 | |
| Primary | 18 (56.3) | 11 (32.4) | 19 (46.3) | 12 (26.1) | |||
| High school | 8 (25) | 6 (17.6) | 11 (26.8) | 19 (41.3) | |||
| Undergraduate and higher | 3 (9.4) | 6 (17.6) | 4 (9.8) | 4 (8.7) | |||
| Occupation | |||||||
| Worker | 9 (28.1) | 8 (23.5) | 0.56 | 11 (26.8) | 21 (45.7) | 0.34 | |
| Retired | 2 (6.3) | 5 (14.7) | 1 (2.4) | 2 (4.3) | |||
| Student | 4 (12.5) | 2 (5.9) | 6 (14.6) | 4 (8.7) | |||
| Unemployed | 17 (53.1) | 19 (55.9) | 23 (56.2) | 19 (41.3) | |||
| Marital status | |||||||
| Married | 24 (75.0) | 22 (64.7) | 0.36 | 30 (73.2) | 30 (65.2) | 0.42 | |
| Single | 8 (25.0) | 12 (35.3) | 11 (26.8) | 16 (34.8) | |||
| People living with the patient | |||||||
| Single | 3 (9.4) | 2 (5.9) | 0.58 | 1 (2.4) | – | 0.29 | |
| Family | 29 (90.6) | 32 (94.1) | 40 (97.6) | 46 (100.0) | |||
| Income status | |||||||
| Middle | 16 (50.0) | 21 (61.8) | 0.34 | 12 (29.3) | 29 (63.0) | 0.004 | |
| Low | 16 (50.0) | 13 (38.2) | 29 (70.7) | 17 (37.0) | |||
| Smoking | |||||||
| Yes | 9 (28.1) | 17 (50.0) | 0.69 | 8 (19.5) | 18 (39.1) | 0.09 | |
| No | 23 (71.9) | 17 (50.0) | 33 (80.5) | 28 (60.9) | |||
| Alcohol | - | ||||||
| Yes | 0 (0.0) | 2 (5.9) | 0.16 | 1 (2.4) | 46 (100.0) | 0.29 | |
| No | 32 (100.0) | 32 (94.1) | 40 (97.6) | ||||
Disease characteristics of the TB patients about the disease
It was determined that 34.1% of the patients in the TB intervention group and 20.6% of the patients in the control group had symptoms of cough, sputum and night sweating together and all the groups had a homogeneous distribution in terms of disease-related characteristics except the patients in the control group were not taking drugs regularly and were not reporting for regular checks (Table II).
| Characteristic | Intervention n=32 (%) | Control n=34 (%) | p value |
|---|---|---|---|
| Diagnosing institution | |||
| Tuberculosis dispensary | 2 (6.2) | 3 (8.8) | 0.51 |
| State/Private hospital | 24 (75.0) | 21 (61.8) | |
| University hospital | 6 (18.8) | 10 (29.4) | |
| Complaints | |||
| Cough | 3 (9.4) | 5 (14.7) | 0.44 |
| Sputum | 3 (9,4) | 0 (0.0) | |
| Cough and sputum | 5 (15.6) | 12 (35.3) | |
| Night sweats | 2 (6.3) | 2 (5.9) | |
| Haemoptysis | 0 (0.0) | 2 (5.9) | |
| Weight loss | - | 1 (2.9) | |
| Cough, sputum and night sweats | 10 (31,3) | 7 (20.6) | |
| Cough, sputum and weight loss | 9 (28.1) | 5 (14.7) | |
| Hospitalization due to tuberculosis | |||
| Yes | 2 (6.2) | 3 (8.8) | 0.69 |
| No | 30 (93.8) | 31 (91.2) | |
| Precautions taken to prevent infection | |||
| Using mask | 17 (53.1) | 16 (47.1) | 0.58 |
| Separate room | 0 (0.0) | 1 (2.9) | |
| None | 15 (46.9) | 17 (50.0) | |
| Barrier of medication use | |||
| Yes | 21 (65.6) | 26 (73.5) | 0.49 |
| No | 11 (34.4) | 8 (26.5) | |
| Reason for barrier (n: 21/26) | |||
| Forgetfulness | 18 (85.7) | 11 (42.3) | 0.004 |
| Feeling good | 3 (14.3) | 7 (26.9) | |
| Not willing to take drugs | 0 (0.0) | 8 (30.8) | |
| Coming for controls regularly | |||
| Yes | 32 (100.0) | 26 (76.5) | 0.003 |
| No | 0 (0.0) | 8 (23.5) | |
| Side-effects of the drugs | |||
| Yes | 10 (31.2) | 9 (26.5) | 0.67 |
| No | 22 (68.8) | 25 (73.5) | |
| Experienced side-effects (n: 10/9) | |||
| Digestive system | 7 (70.0) | 7 (77.8) | 0.38 |
| Pain | 3 (30.0) | 2 (22.2) | |
| Comorbid conditions | |||
| Yes | 12 (37.5) | 9 (26.5) | 0.34 |
| No | 20 (62.5) | 25 (73.5) | |
| Another tuberculosis patient in the family | |||
| Yes | 8 (25.0) | 9 (26.5) | 0.89 |
| No | 24 (75.0) | 25 (73.5) | |
| Relation with the patients (n: 8/9) | |||
| Mother | 1 (12.5) | 2 (22.2) | 0.43 |
| Father | 2 (25.0) | 2 (22.2) | |
| Sibling | 5 (62.5) | 3 (33.4) | |
| Spouse | 0 (0.0) | 2 (22.2) | |
| Getting information on tuberculosis | |||
| Yes | 18 (56.3) | 21 (61.8) | 0.65 |
| No | 14 (43.7) | 13 (38.2) | |
| Information source (n: 18/21) | |||
| Physician | 8 (44.4) | 9 (42.9) | 0.76 |
| Nurse | 7 (38.9) | 10 (47.6) | |
| Other | 3 (16.7) | 2 (9.5) | |
| Feeling when the patients heard about the disease for the first time | |||
| Sadness | 13 (40.6) | 5 (14.7) | 0.16 |
| Denial | 8 (25.0) | 15 (44.1) | |
| Acceptance | 1 (3.1) | 1 (2.9) | |
| Attributing to fate | 1 (3.1) | 3 (8.8) | |
| Disregarding | 1 (3.1) | 1 (2.9) | |
| Getting angry | 2 (6.3) | 0 (0.0) | |
| Being sad and not accepting | 6 (18.8) | 9 (26.6) | |
| Being able to tell that he/she has tuberculosis | |||
| Yes | 10 (31.3) | 5 (14.7) | 0.11 |
| No | 22 (68.7) | 29 (85.3) | |
| Effect of the disease on family and circle relations | |||
| Decreased/impaired | 24 (75.0) | 28 (82.4) | 0.52 |
| No change | 7 (21.9) | 6 (17.6) | |
| Strengthened/increased | 1 (3.1) | 0 (0.0) | |
| Assessing disease | |||
| Thinking that he/she will never recover | 7 (21.9) | 14 (41.2) | 0.08 |
| Thinking that he/she will be able to recover | 13 (40.6) | 6 (17.6) | |
| No view | 12 (37.5) | 14 (41.2) | |
| Views about possible problems in case of not using drugs regularly | |||
| Resistant tuberculosis develops | 3 (9.4) | 2 (5.9) | 0.8 |
| Contagiousness does not get better | 3 (9.4) | 2 (5.9) | |
| Recovery takes long | 10 (31.2) | 14 (41.2) | |
| Do not know | 16 (50.0) | 16 (47.0) | |
| Effect of tuberculosis on his/her own life | |||
| Yes | 22 (68.8) | 28 (82.4) | 0.197 |
| No | 10 (31.2) | 6 (17.6) | |
Characteristics of the contacts about the disease
It was determined that 43.9% of the contacts in the intervention group and 34.8% of the contacts in the control group were the spouses of TB patients and the contacts had a homogeneous distribution in terms of these characteristics except for the affinity to the TB patients and the ways of protection from TB (Table III).
| Characteristic | Intervention n=41 (%) | Control n=46 (%) | p value |
|---|---|---|---|
| Relation with the tuberculosis patient | |||
| Mother | 6 (14.6) | 1 (2.2) | 0.02 |
| Father | 5 (12.2) | 3 (6.5) | |
| Siblings | 0 (0.0) | 6 (13.0) | |
| Children | 12 (29.3) | 20 (43.5) | |
| Spouse | 18 (43.9) | 16 (34.8) | |
| Getting information on tuberculosis | |||
| Yes | 18 (43.9) | 24 (52.2) | 0.44 |
| No | 23 (56.1) | 22 (47.8) | |
| Transmission of tuberculosis | |||
| Eating from the same | 2 (4.9) | 7 (15.2) | 0.11 |
| Blood path | 1 (2.4) | 2 (4.3) | |
| Respiratory tract | 18 (43.9) | 25 (54.3) | |
| Do not know | 20 (48.8) | 12 (26.1) | |
| Protection from tuberculosis | |||
| Vaccination | 18 (43.9) | 27 (58.7) | 0.01 |
| Mask | 0 (0.0) | 6 (13.0) | |
| Drug | 4 (9.8) | 1 (2.2) | |
| Do not know | 19 (46.3) | 12 (26.1) | |
| Getting information about the use of prophylactic drugs | |||
| Yes | 1 (2.4) | 3 (6.5) | 0.36 |
| No | 40 (97.6) | 43 (93.5) | |
| Precautions to be taken when living in the same environment with the tuberculosis patients | |||
| Using mask | 12 (29.3) | 20 (43.5) | 0.38 |
| Ventilating house | 4 (9.7) | 3 (6.5) | |
| Do not know | 25 (65.0) | 23 (100) | |
| Desire to use prophylactic drug by the contact for 6 months | |||
| Yes | 30 (73.1) | 37 (80.4) | 0.66 |
| No | 2 (4.9) | 1 (2.2) | |
| Neutral | 9 (22.0) | 8 (17.4) | |
| Effect on the relations with the tuberculosis patient | |||
| Decreased | 30 (73.2) | 34 (73.9) | 0.94 |
| Did not change | 11 (26.8) | 12 (26.1) | |
Comparison of the intergroup and intragroup change of treatment adherence
It was determined that the TADQ mean (SD) scores of the patients in the TB intervention group at the beginning and in 1st, 3rd and 6th months were 80.4 (7.97), 117.8 (6.3), 137.7 (7.5) and 143.2 (4.5), respectively, and the TB adherence increased as the follow-up period increased. The difference between different times was statistically significant (p<0.05). The MMAS-8 mean (SD) scores of the patients in the contact intervention group at the beginning and in the 1st, 3rd and 6th months were 3.6 (1.3), 5.5 (0.7), 7.2 (0.8), 7.7 (0.7), and those of the control group were 5.7 (1.4), 4.3 (1.4), 1.8 (1.5), 0.7 (1.4), respectively, (p<0.05; Table IV).
| TADQ | Tuberculosis intervention (n=32) | Tuberculosis control (n=34) | Z | PIntergroup |
|---|---|---|---|---|
| Beginning | 80.4 (7.97) | 88.1 (7.1) | −3.731 | 0.001 |
| 1st month | 117.8 (6.3) | 84.5 (9.8) | −6.959 | 0.001 |
| 3rd month | 137.7 (7.5) | 75.9 (7.9) | −6.989 | 0.001 |
| 6th month | 143.2 (4.5) | 65.2 (9.2) | −6.987 | 0.001 |
| χ2 | 89.389 | 77.281 | ||
| Pintragroup | 0.001 | 0.001 | ||
| Morisky 8 item medication adherence scale | Contact intervention | Contact control | Z | PIntergroup |
| (n=41) | (n=6) | |||
| Beginning | 3.6 (1.3) | 5.7 (1.4) | −5.567 | 0.001 |
| 1st month | 5.5 (0.7) | 4.3 (1.4) | −4.028 | 0.001 |
| 3rd month | 7.2 (0.8) | 1.8 (1.5) | −8.102 | 0.001 |
| 6th month | 7.7 (0.7) | 0.7 (1.4) | −8.601 | 0.001 |
| χ2 | 102.12 | 92.47 | ||
| Pintragroup | 0.001 | 0.001 |
Z Mann–Whitney U test, χ2 Freidman test. Freidman test and Dunn’s multiple comparison test were used in the intragroup comparison and Mann–Whitney U test was used in the intergroup comparison. TADQ Tuberculosis adherence determination questionnaire
Change in treatment adherence during the follow-up
In the examination of the month-based change of the TB adherence determination questionnaire during the follow-up in the TB patients, it was found that the change between TADQ mean scores of the intervention group at the beginning and in the 1st, 3rd and 6th months and the change between mean scores in the 1st–3rd months and the 1st–6th months were statistically significant (p<0.05; Table V).
| Group | Tuberculosis group TADQ | Contact group Morisky 8-Item Medication Adherence Scale |
|---|---|---|
| Intervention | p value | p value |
| Beginning–End of the 1st month | 0.002 | 0.002 |
| Beginning–End of the 3rd month | <0.001 | 0.001 |
| Beginning–End of the 6th month | <0.001 | 0.001 |
| 1st–3rd month | <0.001 | 0.001 |
| 1st–6th month | 0.001 | 0.001 |
| 3rd–6th month | 0.100 | 0.114 |
| Control | p value | p value |
| Beginning–End of the 1st month | 0.673 | 0.021 |
| Beginning–End of the 3rd month | <0.001 | 0.001 |
| Beginning–End of the 6th month | <0.001 | 0.001 |
| 1st–3rd month | <0.001 | 0.001 |
| 1st–6th month | <0.001 | 0.001 |
| 3rd–6th month | 0.002 | 0.058 |
TADQ TB adherence determination questionnaire em space MMAS-8 Morisky 8-item medication adherence scale
DISCUSSION
Adherence to treatment is important for successful TB treatment. It has been reported that contagiousness of TB, the lack of information about the patients, lack of the patients’ knowledge about the importance of completing the treatment, forgetting taking the drugs, the side-effects of drugs, symptomatic recovery, inadequate clinical follow-up of the patients and taking inadequate training on TB also affect adherence to treatment negatively.21–23
It has also been reported that the adherence to TB treatment varies between 20% and 80% and non-adherence to TB treatment is the most serious obstacle in the control of the disease. For this reason, approaches such as tele-follow-up may be used to increase treatment adherence of patients.11
We aimed to increase the treatment adherence by the training and telephone follow-up provided for the TB patients and contacts by the nurses. The main factor in the TB treatment is to get drugs regularly. However, patients do not take drugs regularly due to various reasons.
Stopping drugs or taking them irregularly may cause the TB bacillus to appear again and reproduce, drug resistance to develop, and patients may get worse and then die.24 In a study conducted in Turkey, it was determined that 38% of TB patients did not use drugs regularly, 19% stopped taking drugs when they felt good, 35% did not know the side-effects of drugs and 49% did not believe that drugs would heal them.15 Another study found that 23.8% of the patients took their drugs intentionally,25 and Fang et al., found that 24.5% of the patients forgot to take their drugs and 19.5% stopped their treatment as they had symptomatic recovery.8 Furthermore, in this study, it was determined that the patients stopped getting drugs in parallel with the given results due to similar reasons.
TB affects individuals physiologically, psychologically and socially. Because the patients have problems such as exclusion from their families and society, domestic problems, social isolation, stigmatization, loneliness, anger, decrease in self- esteem, depression, despair and lack of social support.26 In their study, Açikel and Pakyüz found that 50% of the patients25 did not state that they were diagnosed with TB to their surrounding and Şimsek et al., found that 37.1% of the patients did not state that they were diagnosed with TB to their circle.26 In a study assessing the emotions of the patients felt after the diagnosis, it was determined that 43.4% of them felt sorry, 12.8% could not accept the disease and 28.6% had reactions such as pessimism, fear, anger and anxiety.27 Also in this study, it was found that the patients in the intervention and control groups used similar expressions at different rates such as ‘not being able to accept the disease, not being able to tell other that they suffered from TB and believing that they would never get well’.
A ‘contact’ person is one who shares the same environment with the TB patient and is exposed to MTB. In a screening study by Putra et al., in 2019 the average age of contacts was 38.6 (14.1) years.28 Kolsuz et al., found that 20.3% of the cases were spouses of the contacts, 41.7% were the children of the contacts, 12.3% were parents of the contacts and 9.2% were siblings of the contacts.29 We found that the average age of the patients in the contact intervention and control groups was compatible with the literature; however, the socio-demographic characteristics such as gender, education and occupation were different.
Similar studies done in various countries have reported that the treatment adherence rate is low and the non-adherence increases during the treatment period.14 Kolsuz et al., found that 41.8% of the contacts included in the protective treatment did not use drugs regularly, 38.4% could not complete the treatment, 22.4% used drugs between 1 and 3 months, 69.4% used drugs between 4 and 6 months and 8.2% used drugs between 7 and 9 months.29
In the randomized controlled study by Tola et al. in which psychological counselling and adherence training was provided for the patients, they found that the non-adherence levels of the intervention and control groups varied between 19.4% and 19.6% at the beginning, and decreased to 9.5% in the intervention group after the intervention but this rate increased to 25.4% in the control group.30 In accordance with this data, it was observed that all members of health teams, primarily nurses, had important responsibilities in providing and maintaining the adherence to treatment. The most important aim of nursing care is to protect and improve health and provide rehabilitation.
As technology has developed, service fields have become different and this has allowed nurses to make changes in the service they provide for the solution of health problems.31,32
Telephone is one of the technologies that can be used in this field. In the telephone follow-up, nurses perform their nursing interventions by offering recommendations for the individuals, consulting them, informing them and directing them to the required places in emergency cases. Furthermore, they answer the questions of patients and encourage them.31,33
In the literature, it has been emphasized that recovery can be achieved in patients with chronic diseases in particular using telephonic counselling by professional nurses.33 Guix- Comellas et al., found that training and interviews with telephonic follow-up performed under the leadership of a nurse increased the treatment adherence of the patients from 74.7% to 87.8%.34 In the randomized controlled study by Taherian et al., training was provided for TB patients systematically in four sessions and they observed that there was a difference in the knowledge and applications of the patients in the intervention group.35
In a mobile-based study done in Thailand, it was concluded that treatment non-adherence (7.5%) of patients in the intervention group was lower compared to the control group (27.5%) and the mobile system was effective in preventing non-adherence.36 In their study, Nagaraja et al., determined that the use of patient-centred mobile technology decreased drug dose skip and contributed to treatment adherence of the patients, similar to other digital technologies.37
Chang et al., reported that latent TB patients receiving INH treatment were followed by nurses by telephone and the treatment adherence of the patients increased three times after the follow-up.38
Systematic review and meta-analyses recommend the use of patient training and counselling and the reminders such as SMS and digital health technologies to increase treatment adherence of patients.22,39,40 These also suggest that text messaging reminders may be an important tool to achieve optimal feedback response in resource-limited settings.41 In our study, the TADQ mean score in the TB intervention group was moderate at the beginning and it increased in months and reached the maximum in the 6th month. Furthermore, through the training, counselling and telephone follow-up provided for the patients when they applied to the dispensary and in the following months, it was observed that ‘the patients understood the importance of treatment, can express themselves better, had knowledge on the treatment and possible side-effects and knew whom they can consult when they faced a problem, and the problems were determined and solved in the early period by the telephone follow-up performed frequently’. As a result of the SMS sent every day, the patients provided positive feedback about the training and telephone follow-up with expressions such as ‘I do not forget taking drugs, when I forget, I remember it with the SMS I get from phone and take it’, ‘I will not stop taking drugs before 6 months of the treatment’, ‘I can share easily when I have any problem’.
In the TB control group, TADQ mean score was over the average at the beginning and decreased in months. This indicated that the adherence levels of the patients decreased over time. The fact that the symptoms experienced intensely at the beginning decreased within time and even they disappeared suggested that the patients became unwilling to take drugs as they thought that they recovered. As is known, factors such as lack of knowledge about the treatment period, failure of the importance of completing the treatment by patients, forgetfulness and unwillingness for getting drugs are amongst the obstacles for regular medication.
In the literature, it has been stated that the patients do not know the importance of the medication period and completing the treatment and they think that they do not believe that the drugs will heal them.8,15,23 Also in our study, almost half the patients in the intervention and control groups answered the question ‘what will happen in case they don’t get drugs regularly’ as ‘I don’t know’. This indicates that the awareness level about TB is inadequate. In the contact intervention group, it was observed that MMAS-8 mean scores of the patients were under the average level at the beginning and reached the maximum level in the 6th month increasing as the patients completed the treatment. It was observed that the contacts understood the importance of the treatment, recognized the TB risk and understood the importance of completing the treatment’ through the training, counselling and telephone follow-up provided. These results indicated that necessary training and follow-up should be planned and provided also for the relatives of TB patients when their follow-up and treatment are being done. Thus, in our study, the MMAS-8 mean scores decreased in the contact control group as from the beginning, even decreased to 1.8 (1.5) in the 3rd month and 0.7 (1.4) in the 6th month, which showed that a majority of patients left the protective treatment.
Hence, relatives of TB patients also needed support for treatment and follow-up. Furthermore, the fact that contacts left the prophylactic treatment due to thoughts such as ‘the contagiousness of our patient got over, we are ok, I am not sick, why do I use drugs, I don’t want to use drugs, I am already protected’ indicated that the contacts did not have enough awareness about the treatment.
Also in the literature, it has been reported that 2%–3% of the contacts of the patients may be diagnosed with TB and the disease may develop in 5%–12% of these people in 2 years.42
In our study one-fourth (25%) of our patients’ family had another TB patient and this showed that individuals who were patients were contacts in the past. This rate was 32.9% in the study by Oral and 35% in the study by Hazerli and Karabacak Gülseven.13,43 These results suggest that contacts were at higher risk and individuals who were not treated or did not use protective treatment regularly may be new TB patients. Hence, contacts also need systematic training and close follow-up.
Limitations
Patients with extrapulmonary TB and contacts were not included in the study, the patients using cell phones as a communication tool were included, the adherence was assessed only with the scale and no clinical data were used in the study.
Conclusion
In this study assessing the effect of the training and telephone follow-up provided by nurses to TB patients and contacts during the 6-month treatment and follow-up, it was determined that the adherence level in the TB and contact intervention group increased significantly from the beginning and the adherence level decreased in the TB and contact control group from the beginning. Based on these results, it is recommended to repeat the training provided for patients at the beginning systematically, take information about the patients by following their clinical status and to provide for patients knowledge about their own outcomes, to use the reminders such as SMS to overcome barriers to medication adherence and assess the treatment adherence during the treatment to increase the medication period of the patients and contacts.
Relevance to clinical practice
Training and telephone follow-up are amongst the methods which can be used, especially by nurses in increasing the treatment adherence of the TB patients and contacts. These approaches may be applied regularly and constantly to prevent the disease to spread in the society. For this reason, it is important for nurses to have an active role in the management of the disease, determine the patients who do not use drugs correctly in the early period and apply the required interventions as soon as possible in the treatment adherence of TB patients and contacts.
ACKNOWLEDGEMENTS
We would like to thank all the patients who agreed to participate in the study. Authors agreed to adhere all copyright requirements. The use of the MMAS diagnostic adherence assessment instrument is protected by US copyrighted and trademarked laws. Permission for use is required. A license is available from - Morisky Medication Adherance Research LLC., Lindura Ct., Las Vegas, USA.
Conflict of interest
None declared
References
- What is TB? 2018. How is it treated?. WHO; Available at www.who.int/features/qa/08/en (accessed on 20 Nov 2019)
- [Google Scholar]
- Stop TB field guide 6: Using contact investigation to improve TB case detection. 2018 Available at https://stoptb/strategicinitiative.org/elearning/wp/content/uploads/2019/04/STBFG_06pdf (accessed on 20 Nov 2019)
- [Google Scholar]
- Tüberkülozda koruyucu tedavi In: Özkara Ş. Kılıçaslan Z, editör. Tüberküloz. İstanbul: Toraks Kitapları; 2010.
- [Google Scholar]
- One of the major problems in tuberculosis control: Adherence to therapy. TAF Prev Med Bull. 2009;8:75-82.
- [Google Scholar]
- Which patients are able to adhere to tuberculosis treatment? A study in a rural area in the Northwest part of Turkey. Jpn J Infect Dis. 2005;58:152-8.
- [CrossRef] [PubMed] [Google Scholar]
- Follow-up of patients with type 2 diabetes via cell phone: Randomized controlled trial. Clin Exp Health Sci. 2013;3:173-83.
- [CrossRef] [Google Scholar]
- Factors influencing completion of treatment among pulmonary tuberculosis patients. Patient Prefer Adherence. 2019;13:491-6.
- [CrossRef] [PubMed] [Google Scholar]
- Factors influencing knowledge on completion of treatment among TB patients under directly observed treatment strategy, in selected health facilities in Embu County, Kenya. Pan Afr Med J. 2016;22:234.
- [CrossRef] [PubMed] [Google Scholar]
- Profesessional and legal responsibilities of nurses in drug administration. Maltepe Univ J Nurs Sci Art. 2009;2:86-93.
- [Google Scholar]
- Protection from tuberculosis and the role of the nurses. J Intern Med Nurs Spec Top. 2017;3:45-9.
- [Google Scholar]
- Tuberculosis compliance determination scale: Validity and reliability study In: In: 13th National internal medicine congress. 2011.
- [Google Scholar]
- Non compliance to tuberculosis therapy: A cross sectional study. J App Pharm. 2015;7:129-31.
- [CrossRef] [Google Scholar]
- Barriers about the regular drug use in the tuberculosis patients. J Adv Res Health Sci. 2018;1:1-10.
- [Google Scholar]
- 2019. Available at www.health.nsw.gov.au/pds/activepdsdocuments/gl2019_003.pdf (accessed on 20 Nov 2019)
- Antecedents of adherence to antituberculosis therapy Birmingham: The University of Alabama at Birmingham [Dissertation]; 1996.
- [Google Scholar]
- Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10:348-54.
- [CrossRef] [PubMed] [Google Scholar]
- Effect of intensive blood-pressure treatment on patient-reported outcomes. N Engl J Med. 2017;377:733-44.
- [CrossRef] [PubMed] [Google Scholar]
- Cost-effectiveness of intensive versus standard blood-pressure control. N Engl J Med. 2017;377:745-55.
- [CrossRef] [PubMed] [Google Scholar]
- Factors influencing treatment default among tuberculosis patients in a high burden province of South Africa. Int J Infect Dis. 2017;54:95-102.
- [CrossRef] [PubMed] [Google Scholar]
- Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies. PLoS Med. 2018;15:e1002595.
- [CrossRef] [PubMed] [Google Scholar]
- Factors influencing adherence to tuberculosis treatment in Asmara, Eritrea: A qualitative study. J Health Popul Nutr. 2018;37:1.
- [CrossRef] [PubMed] [Google Scholar]
- Türkiye'de tüberkülozun kontrolü için basvuru ki-tabi. In: TC Saglik bakanligi verem savasi daire bas-kanligi. Ankara: Rekmay Ofset; 2003.
- [Google Scholar]
- Evaluating the stigma on patients with tuberculosis. Florence Nightingale J Nurs. 2015;23:136-45.
- [CrossRef] [Google Scholar]
- Evaluation internalized stigma of tuberculosis patients. Int Ref J Nurs Res. 2016;7:156.
- [CrossRef] [Google Scholar]
- The relation of tuberculosis to life events and its perception. J Turgut Ozal Med Cent. 2008;15:249-55.
- [Google Scholar]
- The Implementation of early detection in tuberculosis contact investigation to improve case finding. J Epidemiol Glob Health. 2019;9:191-7.
- [CrossRef] [PubMed] [Google Scholar]
- The evaluation of pulmonary tuberculosis patients enrolled to eskisehir deliklitas tuberculosis control dispensary. Tuberk Toraks. 2003;51:163-70.
- [Google Scholar]
- Psychological and educational intervention to improve tuberculosis treatment adherence in Ethiopia based on health belief model: A cluster randomized control trial. PLoS One. 2016;11:e0155147.
- [CrossRef] [PubMed] [Google Scholar]
- The effect of home telephone monitoring on recovery of patients who underwent hip arthroplasty. Ege University Health Sciences Institute. Izmir. [Unpublished Doctoral Thesis]
- [Google Scholar]
- Registered nurses' association of Nova Scotia. 2002. Available at www.rnans.ns.cab (accessed on 10 Mar 2020)
- [Google Scholar]
- A current approach in nursing practice: Telephone usage. J Educ Res Nurs. 2012;9:30-5.
- [Google Scholar]
- Impact of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: A nonrandomized controlled trial. J Adv Nurs. 2018;74:1819-30.
- [CrossRef] [PubMed] [Google Scholar]
- Investigating the effect of education on knowledge and practice in preventing tuberculosis in eastern Iran. Int J Health Promot Educ. 2020;58:83-91.
- [CrossRef] [Google Scholar]
- Ensuring tuberculosis treatment adherence with a mobile-based CARE-call system in Thailand: A pilot study. Infect Dis. 2020;52:121-9.
- [CrossRef] [PubMed] [Google Scholar]
- "Kill-TB" drug reminder mobile application for tuberculosis patients at Bengaluru, India: Effectiveness and challenges. J Tuberc Res. 2020;8:1-10.
- [CrossRef] [Google Scholar]
- House calls by community health workers and public health nurses to improve adherence to isoniazid monotherapy for latent tuberculosis infection: A retrospective study. BMC Public Health. 2013;13:894.
- [CrossRef] [PubMed] [Google Scholar]
- The impact of digital health technologies on tuberculosis treatment: A systematic review. Eur Respir J. 2018;51:1701596.
- [CrossRef] [PubMed] [Google Scholar]
- Mobile phone based interventions for promoting adherence to tuberculosis treatment: A systematic review and meta-analysis. Lancet. 2015;386:S29.
- [CrossRef] [Google Scholar]
- Study of the structure and functioning of referral mechanism of patients receiving treatment and records linkage under revised national tuberculosis control programme (RNTCP) of government of India. Indian J Tuberc. 2017;64:77-82.
- [CrossRef] [PubMed] [Google Scholar]
- Tüberkülozdan ilaçla korunma. 2012. 21st Yüzyılda tüberküloz sempozyumu ve II Tüberküloz laboratuvar tani yöntemleri kursu, Samsun. Available at www.klimik.org.tr (accessed on 10 Nov 2019)
- [Google Scholar]
- Investigation of the compliance status of tuberculosis patients in zeytinburnu district of istanbul province to current treatment and the factors affecting this. Ankara Yıldırım Beyazıt University Health Sciences Institute. Ankara: Master’s Thesis;
- [Google Scholar]
