Case Holding and Patient Compliance and Motivation
Item
- Title
- Case Holding and Patient Compliance and Motivation
- Creator
- Marie D'Souza
- Date
- 1985
- extracted text
-
(35)
Medico friend circle^-_Anmia\ ''•?et 1035
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£A£E_HQLDINO ?1ND~PATIENT_COMPLIANCE § MOTIVATION
MARIE DJ SOUZA
In India today we see a situation of extreme poverty
of the masses and one of‘the highest rates of Tuber
culosis in the world. For every 1000 population
there are 16 persons with active tuberculosis lesions 9
4 of whom are infectious.(sputum positive)
Yet is is said that success in treatment of
Tuberculosis depends on quality and duration of
chemotherapy.
It is also established that hospitalisation,
rest and special diets^re not needed in the majority
of cases.
I will not consider here the' fact that in deve
loped countries the number of cases showed a decline
when the standard of living improved. Nor will I
dwell on the fact that the basic needs of food,
water and health care are lacking for 80% of our
population living in rural areas.
If success depends on quality and duration of
chemotherapy then case-holding forms a very important
mart of TB contorl. 100% case-holding is however
very difficult to attain.
The early sixties saw the evolution of the
concept within the NTP of offering TB services as a
part of comprehensive health care by the general
services. This was done so that treatment centres
could be nearer the houses of patients, who could
take treatment without disrupting excessively their
normal life. The belief that Tuberculosis is a
problem of thickly populated cities and slums is a
thing of the past. Pulmonary Tuberculosis is as
prevalent in rural .areas as in cities. 'And on the
basis of distribution of population one can except
2 to 3 cases in each village, with a higher rate in
tribal areas.
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CASE FINDING
Tuberculosis is classified as one of the biggest
health problems among our vast ill-served rural
populationo So case-finding in the rural areas
needs to be established and it is here too that
C\SE-HOLDING has to be given importance so that the
best benefit can be drawn from the available
resources of men, money and materials.
To-day every PHI is supposed to have a • microscoping centre’** . . . though there is a query as
to how efficient they are where established. Baily
says that each PHI should diagnose nearly 2000
basillary cases in a year. This can be achieved by
examining the sputum of all new patients attending
with symptoms of chronic cough.
If the real aim of case-finding is treatment,
then that of case-holding is completion of
treatment, while-the aim of treatment is both relsf
3S well as £lcsure
„sources_of
infection. The NTP stresses on the "latter.*** Tt is
the depth of suffering which makes people report to
health centres (felt need) as well as influences
the regularity with which treatment is subsequently
taken (though this statement has been questioned).
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Treatment efficiently 'administered and taken will
.relieve suffering and also have an epidemiological
impact.
Efficient treatment requires free availnbiligy
of drugs, ‘suitable drug regimens, freedom from toxic
reactions, regularity of drug intake and adequate
duration of treatment. This implies health services
easily accessible, daily, with health personnel who
ore capable and able to deal with patients with
sympathy and consideration.
Unfortunately thre'efourth of patients who have
felt-need are being denied opportunities of getting
their suffering alleviated due to faulty diagnosis.
In many instances the sputum of patients with chronic
cough is not examined. And of the patients who are
diagnosed os having Tuberculosis 7O?4 are lost during
the entire course of treatment.
a
A moderately infectious Tuberculosis patient is
capable of infecting 10 to 12 individuals within a
periods of one year. This patient untreated has a
survival time of 2 years (it is capable of infecting
24 individuals) Agnin, this patient treated irregularly
has his life span prolonged and th? number of people
he infects keens multiplying.
In terms of human suffering, the loss caused by
TB is incalculable for the individual patient himself
- physical, psychological, 'social, material and for
his family too. Economically TB accounts for an
estimated loss to the notion of Rs.1000 crores in
man hours.
All this should make us realise the urgency of
Case - Holding
K.iTIONAL^T.UB^RCULOSIS PROGR
A. step in this direction was taken when the NTP
brought treatment centres closer to patients homes.
Further in order to ensure regular and adequate drug
intake by patients for a period of atleast 12 months,
•a treatment organisation with limited supervision
and machinery for defaulter retrieval has been
provided. The main objective is detection of a
maximum number of tuberculosis patients, specially
sputum positive, and efficient treatment.
Here follows a synopsis of the programme
1. Every person reporting to the PHI with cough of
more than 2 weeks duration is requested to give his
sputum for examination.. If sputum positive,
treatment is started 6n the same day.
Every-MPW is required to collect the sputum of
eligible symptomatics (i.e._ cough, fever or
chest-.pa in of more than 2 weeks or h aemoptysis)
prepare the smear'and referal slip and hand it
over1to the PHI. The sputum positive cases are
refered back th the MPW who is required to
bring the patients to the PHI for check-up. The
MO. also communicated directly by post with
sputum positive patients.
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2. The sputum negative patients who are suspects are
sent to the nearest Government Health Institute
with facilities for X-ray/ MMR/ Screening.
3. NTP has 5 drug regimens R to . R^ for sputum
positive patients. Those who are sputum negative
are treated with R^. 'Drugs are supplied free of
cost.
4. At initiation of treatment the- patient is moti
vated by the P-1.0. and health visitor in the clinic
with emphasis on completion of treatment. Repeat
motivation is done at each collection ^very month.
5. If the patient does not collect the- drug within 2
days of the appointed date, a postal reminder is
sent and if there is no response for 7 days 9 then
home visits and fresh motivation about importance
of regular treatment is given.
6. There is an effective ’’transfer ?? system which
enables any patient to receive treatment from any
peripheral centre convenient to him.
7. A new patient put on treatment becomes eligible
for first follow-up exam and sputum exam at 6
months. X-Ray exam is optional. Second follow-up
exam is due after 12 months when be th X-Ray and
sputum exam can be ordered.
Default
The above is what the NTP requires. Whether these
requirements are achieved is the big question. And
achievements vary from state to state. Prom reports
it appears that the NTP functions very poorly in the
north of the country, a little better in the south.
It is not surprising that as a result there is
a very high defaulter rate - 70% of patients
diagonosed as having Tuberculosis.
Bancrji defines ’defaulter’ as one whose actions
even after being provided ’’optimal”’ services go
against his own welfare or against the welfare of the
community or both.
In this sense there are very few patin® defaulters because the major impediments to acceptance of
NTP appear to be organisational, managerial and
technical rather than behavioural factors or short
comings in motivation of patients, Therefore there
are more organisation defualters.
This is proved by the many ins‘-ances where
recommendations laid down by NTP are not carried
out.
Very often patients are not told the result of
the sputum exam on the same day, A study has
shown that 11% positive causes do not return to learn
the result of their exam.
should they? Since
no indication or motivation is given and the drugs
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given for their cough have not been effective. \fter
ell patients are not worried about TB bacilli in
sputum. They are worried about fever, cough, chest
pain, anorexia, loss of weight, children starving,
loss- of sexual potency, etc. They expect to be cured
quickly and so decide to go elsewhere for “better”
treetment.
. In fict it his been shown that 52% of infectious
Tuberculosis patients seek medical help of their own
accord and of these 90% ire sent away with cough ■
syrups end tonics.
It .tells badly for the health professionals who
are not properly trained/motivated. Add to this, the
fact that many of them resort to private practice or
corruption. Why should any patient have confidence
in -them? The same can be said of para-medical
personnel, inadequately motivated, trained and
utilised, mal-functioning or lacking (eg. lab tech
nician) Lack of proper supportive supervision, -as
opposed to inspection, odds to the problem.
Lack of communication on the part of organisa
tional personnel leads to misunderstandings,. This
is further heightened by rudeness and results in
default., specially so among the poor who are the
larger -number and yet are pushed aside while preferen
ce is given to the middle class;';
Often a patients arrive at the PHI to find it
closed - either the doctor is away for a meeting so
the rest of the staff also t^ke a holiday, public
holidays aie suddenly declared on the radio,, a camp
is organises and all the staff are involved /' no
one attending to the general health services, much
less to Tuberculosis patients*
Drug yp-’*
^imonts are prescribed but no health
education or motivation is given in many instances.
Patients are as<ed to return after a week or two
because the drugs are.exhausted. when they do return
they find that she colour and form and even the
number of the tablets has changed (eg. INH 100 mg
5 tabs, changed to INH 500 mg 1 tab) No explanation
is given and literate as well as illiterate patients,
are not sure whe'her their drugs have been given
correctly. They iare not question the health perso
nnel and often consume the wrong dosage.
Not all the fault lies 'with the PHI. They are
influence! by decisions from above. Highest
priority is given to Family Welfare Programs, with
ample funds and monetary inducements to promoters
etc. Though on th 20- Point Programme, low
priority is given p TB.
Drug manufacturers have their part to play too
in default. There 1b not much margin of profit in
the production of fi?st line drugs ^nd only one third
of the required quoti *..s manufactured. While second
line drugs, not included in the NTP, are available
easily on the market. \dd to this the wrong prescri
bing habits within the -ountry by private practi
tioners systematically 'dding tonics and other fanci
ful tabl.ts, as also free sale of TB drugs by
chemists without- prescription. How is a patient to
judge whether 2 or 5‘kirds of tablets given at the
PHI ere enough to cure h’.m of his disease when his
neighbour takes 5 or 6 k.nds, wrapped in silver foil,
prescribed by a private Practitioner.
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All the above adds up to organizational default.,
it surprising then that there is lack of patient
complinance and motivation?
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This leaves just a few instances of patient
'’default”. Though, can he be said to "Default" when
he is not provided with ’optimal* services?
Studies show that drop-«uts are maximum within
the first 3 months of treatment irrespective ’ of the
type of regimen the patient is on. However a large
proportion of these drop-outs resort to subsequent
treatment either immediately or after some time
either at -che same PHI or at other health institu
tions public or private. Studies also show that
relief of symptoms, as commonly believed, was not a
cause of default.
Distance of patients home from the treatment
centre exerts a continuous process of selection.
Patients living more than 5 Kms. from treatment
centres take treatment irregularly. Add to this the
monsoons when travel is difficult as bus services
are stopped and even walking on mud roads requires an
effort. Emigration in search of work is another
cause of default.
Poverty has a large part to play. How is patient
to pay for bus fare, corrupt practice, X-Rays etc.
when he draws no income because of his inability to
work.
CASE-HOLD I NG
Improvement in case-holding demands that technical
and organisational methodology cl c ee-holding will
have to be improved, and methods of preventing
default, specially organisational, must be intensified.
For with proper organisation case-holding could
increase by 4&%.
Studies have shown that there is a positive
interaction between good organisation, low default
rate and effective treatment, each supporting the
other. In 1983 the Government of India launched the
new National Health Policy in co-ordination with the
new 20-Point Programme of which Point 14 says
"substantially augment univejrsai. primary health
care facilities and control of Leprosy, TB and
blindness".
Government funds need also to be provided (as
in the NFPP) to "motivate" professional and para
medical health personnel. For example, CHVs and
MPWs bringing sputum positive patients to PHIs
could be "rewarded". While patients themselves
wh* complete treatment could be given a gift.
Government has the money to spend on research and
treatment of Ischaemic Heart Disease Cancer,
Diabetes, Chronic Renal Failure, as also CHOGM,
Asian Games etc. so why not on treatment of TB?
Health personnel-, in general, .definitely
need better orientation, and up-dating as regards
TB treatment. The para-medical workers also, need
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Ps.tient.s__ support each other in taking treatment. So
meetings could be held of patients in each village,
where common problems could be discussed, misunder
standings cleared and difficulties solved where
possible. They also help to remind each other of
visits due to the PHI besides supporting each other
in cases of corrupt practice by health personnel or
getting their rightful demands mej-t’.* This has been my
experience in one village.
Studies need to be conducted to improve community
participation in TB control.
One factor which promotes patient compliance
and motivation is sputum examination done P1-£iodica-_
lly. In one study where- sputum exam was done on '3rd
6th and 9th month after initiation of treatment,
drug collection s^snt up in the period immediately
following it. A physical .check-lip witn weight
taking at every drug collection each month would also
probably help. At present, in many instances the
patient is just sent to the dispensing window-where
he is merely told "Come again next month". Is this
enough motivation?
In case of patients sent for X-Ray exam., proper
instruction to reach the Health Institution, person
to contact, fee to be paid, etc. should be clearly
given. The Referral Centre should also make clear
to the patient that he is being referred back to the
referring centre, presumably more convenient, for
treatment. In case of transfer to another PHI, more
convenient for the patient, ho should be similarly
clearly informed of the person to contact at the
transferred address.
0
OUR ROLE
What role can we of MFC and the Voluntary Health
Sector play in Case-Holding? There arc some that
feel that the Gove *nment HI cannot handle the TB
control program alone. NGOs and other have to
pool in.
As long as NGOs are treating middle class and ri*h•
patients their pooling in will certainly help. They
should follow the guide-lines laid down by the NTP
as .... which are good as sputum positive
patients are concerned. In the case of sputum nega
tive patients it'would be well to remember that XRay alone is not enough to confirm diagnosis of TB.
Studies have shown that defaulters among those
’'cases” based on radiological findings is very high
and that they need strong and more effective moti
vation* Also as many as 98% of sputum negative so
called X-Ray positive cases continued to be sputum
negative after 3 years.
The question arises when treating poor pati
ents . Should they be refused treatment by NGOs?
. . - . specially when they profess to be meant
for the poor? Financially they would’ go under, I
think, if they give free treatment to the poor, On
the other hand the poor cannot afford the whole
course of treatment and would soon become defaulters
with eventual increase in suffering.
One solution could be a closer relationship with
the NTP, which through the DTC Centre, is willing to
supply free drugs on fulfillment of certain
conditions.
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Another solution is to make sure that poor
patients really make use of the PHI services. They
have a right to free treatment and we could help
- them get it. One way to do so that we, at Janseva,
have found helpful is a slidd -show on TB which,
besides emphasising completion of treatment also
informs the community o.n the different steps TB
suspects will have to go through for diagnosis eg.
sputum exam., possible X-Ray, the form, filled in by
the doctor, they will have totake to the referral
centre, and bring back filled in, signed and stamped,
and eventually, free treatment.
When some patients were asked a fee at colle
ction of drugs - they refused to pay saying 1 we are
from Janseva1 they were never pestered again.
The same slide show helped motivation . . .
yet we had patients defaulting in spite of home
visits by us.
and
We should realise that even the most refined
advertisemental techniques using deep motivation,
subliminal perception, etc. have never claimed
10C% success. Personally, I feel that we of MFC
and others in the Voluntary Sector should being
pressure on the Government., so that sufficient
funds are provided to carry out effectively the
National tuberculosis Programme. This would mean
an increase in work load 3 times the present, and
hence increase in personnel, with proper training,
etc •
Above all, pressure has to be brought on the
Government to in turn pressurise the Drug Manufactu
rers into producing the necessary quota of first
live drugs based on a realistic calculation of the
number of patients to be treated.
Marie D1Souza
Janseva Mandal
a
Nandurhar 4 25412
MAHARASHTRA
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REFERENCES:
Anderson S. & Banerji.D.
(1963) Bull.Wld Hlth
Org. 29, 685 - 700
Nagpaul.D.R. Ind. J. Tub., Vol. XIV, No.4
Banerji D. (Apr 1969) Proceedings of XXth Inter
national Tub- Conference
Nagpaul D.R., Vishwanath M.K.
Dwarakanath G.Q97D)
Bull. Wld. Hlth Org- 43, 17-34
Baily G.V.J., Samuel G.E.R. & Nagpaul D.R. Ind.
J. Tub., Vol. XXI, No.3
Nagpaul D.R.
(Jul.1978) Jour. I.M.A. Vol. 71, No. 2
pp44-48
Aneja K.S. & Srikantan K.
(1980) NTI newsletter
17, 78
Banerji D.
(1981) NTI Newsletter X 18, 50
Aneja K.S.
(1982) NTI Newsletter 19, 58
Baily G.V.J.
(APr.1983) Ind. J. Tub., vol.XXX.No.2
Chaulet P. WHO/TB/83.141
Banerji D.
(Apr. 1984) Background Document for
VHAI meet
Sen Binayak: National Tuberculosis Programs some
prob1ems a nd i ssucs
Shiva Miras Towards Rational TB Care - a continuing
Committment
CMC Ludhiana: An approach to TB care
Seetha M.A. of NTI s VriAI D-10. 344/MS-cb/10.383
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