Investigation of Factors Related to Default using Qualitative Methods

1
Investigation of Factors Related to Default using
Qualitative Methods

• Adallah, Rosemary, Frank, Mabuza, Moalosi, Ann,
  Richard, Kayla

2
Methods

• In-depth interviews of health workers in a clinic
• Senior nurse and two community health workers
• Focus group discussion
• Cured patients (3 males and 2 females) age range
  16-50, included both new and relapse cases all
  lived close to clinic
• Interviews by facilitator with manual recording
  of the responses
• Domain analysis by key areas

3
Clinic Scene
4
Focus Group Discussion
5
In Depth Interview
6
Results Domains for Analysis

• Community and household factors
• Health Providers
• Health System / Program
• Patient related factors

7
Results Community and Household Factors-FGD

• Mother motivated patient because another son had
  died from TB
• Religion not a factor Even if you pray, you
  should continue to take your tablets!
• Patient encouraged by sisters because of concern
  about her weight
• My sisters would go to the clinics and collect
  the tablets when I was unable to go myself
• Mixed community response
• Some people would support and others would laugh
  at them and make funny remarks but they were not
  discouraged by that

8
Community and Household Factors-IDI

• Cultural factors used to be a barrier
• TB considered to be a bewitched disease, and
  treatment sought at traditional healers
• Religion not considered to be a risk factor for
  default
• TB-HIV dual infection stigmatized in the
  community
• Nowadays, people think of TB as HIV
• Community support systems for TB exist in the
  community
• Even Traditional healers refer cases to the
  clinic for treatment

9
Health Provider Factors for Default-FGD

• Sisters were supportive and encouraged them and
  treated them well (but senior nurse present at
  FGD)
• Nurses loved them
• I loved the clinic sisters and they also loved
  me

10
Health Provider Factors for Default-Nurses IDI

• Both CHW did not feel that the health provider
  had an effect on default, but the professional
  nurse reported
• TB clients will say, I like this one, I dont
  like that one
• All felt that a shortage of staff affected health
  education and quality of care (only 31 of posts
  filled)
• Training of the staff about TB was considered
  adequate
• Whenever a new activity is introduced in the
  program, training and in-service training is
  organized
• Doctors not mentioned at all

11
Health System/ Program Factors for Default-FGD

• One patient had been invited to participate in an
  annual TB meeting to motivate other TB patients
• Patients did not have to queue with other
  patients, they had their own special room to be
  treated in separate area for infection control
• The distance from the clinic was not a problem
• Duration of treatment was felt to be too
  long-three months would be better

12
Health System/ Program Factors for Default-Nurse
IDI

• Drug supply not a problem, but before using the
  FDC drugs, some shortages in drugs--felt that it
  did not affect default
• Number of pills used to be a problem until the
  introduction of FDC drugs
• Duration used to be a factor, until the Community
  DOTS volunteer program
• The queue was reported to be a problem
• According to the patients, they would like to go
  in and go out
• Patients used to wait for a long time, but now,
  they wait for 10-15 minutes because of DOTS in
  the community but patients prefer immediate
  service.

13
Patient related factors cured patients FGD

• Not supervised self motivated
• I was not supervised, I motivated myself, I told
  myself I am sick and have to complete treatment
• Patient misunderstandings
• I was afraid to share food with other people
• Causes of default thought to be alcohol, feeling
  better after two weeks
• Other times they did not take this seriously,
  play around partying, and forget to come to the
  clinic to take treatment
• Defaulting is not a good thing - you delay
  treatment because it prolongs treatment

14
Patient Related Factors In Depth Interview

• Causes of defaulting given by patients
• Social reasons like travelling or changing or
  moving residence
• Negative attitudes of TB patients towards TB
  treatment Some patients are stubborn!
• TB patients are stubborn people, I must tell
  you!
• Side effects such as loss of libido, vomiting and
  weakness may cause default
• Weak patients default but with community based
  DOTS not a problem

15
Discussion

• Different methods gave different results
• Would have been good to interview defaulters and
  patients still on treatment
• Would have been better to have conducted the FGD
  off the premises and with the senior professional
  nurse not present
• In IDI CDC said she would have answered
  differently. Interesting to know what????

16
Discussion - Agreements

• All agreed that
• access to TB services had improved and that
  patients were satisfied
• good provider patient relationship
• We see the patients every day and we become good
  friends!
• Some patients default after a few weeks because
  they feel better

17
Discussion - Disagreements

• Nurses thought that patients were unhappy to wait
  but the patients were happy with the special room
  for them!
• Staff thought patients preferred some staff but
  not found in FGD
• Interesting differences between different levels
  of nurses e.g. about stigma

18
Conclusion

• Knowledge about TB generally good, patients knew
  that they must take treatment to be cured
• Community based DOTS has reduced pressures on
  patients and health providers!
• Understanding factors for default helps plan
  interventions to improve adherence

19

• Thanks to Ann and her team for making this short
  study successful!