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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 26-30

Positive impact of knowledge about tuberculosis and its treatment on treatment adherence among new smear-positive tuberculosis patients in ward E of Mumbai, Maharashtra, India

1 Department of Community Medicine, SMBT Medical College, Nasik, India
2 Department of Community Medicine, D Y Patil Medical College, Nerul, Navi Mumbai, India
3 Department of Community Medicine, Grant Medical College, Mumbai, India
4 Department of Community Medicine, Chief Intesivist, Deenanath Mangeshkar Hospital, Pune, India

Date of Web Publication25-Jan-2016

Correspondence Address:
Dr. Priya Y Kulkarni
5, Shanti Sadan, Erandawane, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-2296.174788

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Background: Treatment nonadherence is major challenge before tuberculosis (TB) control activities. Treatment adherence is the result of interactions of various factors related to the patient, provider, health setup, type of illness, and sociocultural factors. Aim: The aim was to assess baseline knowledge of new smear-positive TB patients about their disease and treatment and to find its impact on treatment adherence. Methods: New sputum-positive TB patients initiated directly observed treatment short-course in ward E of Mumbai district in first two-quarters of the calendar year were enrolled in the study. They were interviewed by trained interviewer as per pretested semi-structured interview schedules to collect sociodemographic information and to assess their knowledge after verbal consent. Treatment adherence was noted by screening treatment cards after any final outcome of the treatment as per Revised National Tuberculosis Control Program. Data were entered in Microsoft excel and analyzed using SPSS 15.0 software (developed by IBM, Chicago, USA in 2007). Results: Out of 157 patients enrolled, 150 could be interviewed. The majority were in reproductive age group and from class IV and V socioeconomic class. Good knowledge about infectiousness, reasons behind TB, its spread, curability, and treatment duration was found in 29.5%, 28.8%, 16%, 59%, and 22.3%, respectively. 72/150 were treatment adherent and good knowledge about all these aspects was significantly associated with treatment adherence. Most significant association was found with good knowledge about infectiousness of TB (odds ratio: 1.764, P < 0.001). Conclusions: Thorough knowledge regarding TB and its treatment should be given to the TB patients at the initiation of the treatment may help to improve treatment adherence.

Keywords: Knowledge about tuberculosis, treatment adherence, tuberculosisAddress for Correspondence:

How to cite this article:
Kulkarni PY, Kulkarni AD, Akarte SV, Rajhans PA. Positive impact of knowledge about tuberculosis and its treatment on treatment adherence among new smear-positive tuberculosis patients in ward E of Mumbai, Maharashtra, India. Int J Educ Psychol Res 2016;2:26-30

How to cite this URL:
Kulkarni PY, Kulkarni AD, Akarte SV, Rajhans PA. Positive impact of knowledge about tuberculosis and its treatment on treatment adherence among new smear-positive tuberculosis patients in ward E of Mumbai, Maharashtra, India. Int J Educ Psychol Res [serial online] 2016 [cited 2020 Jul 14];2:26-30. Available from: http://www.ijeprjournal.org/text.asp?2016/2/1/26/174788

  Introduction Top

Tuberculosis (TB) is a major public health problem especially in South East Asian region and other under-developed countries. India is the highest TB burden country. It contributes more than 25% of the world's incident TB cases.[1] Increase in anti-TB drug resistance has worsened the situation. Nonadherence to Anti-Tuberculosis Treatment (ATT) remains a major challenge in TB control activities. It contributes significantly to the development of prolonged infectiousness, drug resistance, relapse, and death.[2] Wide range of factors interact, impacting treatment adherence like socioeconomic condition, knowledge of TB and its treatment, extent of patient-provider interaction, stigma, illness representation, etc.[3]

New sputum smear positive (NSP) TB patients spread TB through droplet nuclei and maintain the pool of TB infection in the community.[4] Their knowledge about TB, its spread, treatment, and other parameters is important, so that if they apply their knowledge, progress of TB disease, and adverse treatment outcomes can be halted individually as well as at the community level.[5] Assessment of knowledge of NSP TB patients about their disease and treatment is needed to assess impact of ongoing Information, Education, and Communication (IEC) activities and TB control activities regarding patients' education under Revised National Tuberculosis Control Program (RNTCP).[6]

In the present study, our aim was to assess baseline knowledge of NSP TB patients about their disease and treatment and to find its impact on treatment adherence.

  Methods Top

It was a directly observed treatment short-course (DOTS) center-based prospective cohort study conducted at 21 DOTS centers in E-ward of Mumbai Municipal Corporation. Study population was all NSP TB patients initiated on cat-I treatment regimen of DOTS during the period from 1st January to 30th June of a calendar year. Seriously ill and patients unwilling to participate in the study were excluded. Study was approved by Ethical Committee, Grant Medical College and by the Member Secretary, Mumbai District TB Control Society. A semi-structured interview schedule pretested on 10 patients, they were excluded from the study. Suitable modifications were done to achieve the final semi-structured interview schedule and were translated into local language. It included information regarding sociodemographic characteristics and knowledge regarding TB and its treatment. After taking verbal consent, patients were interviewed by trained interviewers during intensive phase. Treatment adherence was determined after final outcome as per RNTCP using treatment cards of the patients. At the end of the study, data were entered in Microsoft excel and then imported in SPSS 15.0 (developed by IBM, Chicago, USA in 2007) data editor for further analysis. Frequencies and proportions were enlisted and risk estimates with 95% confidence intervals were calculated. Appropriate tests of significance were used wherever necessary.

Definitions used:

  1. Treatment adherence: No interruption ATT any time for >1-month [7]
  2. Treatment nonadherence: Interruption of ATT any time during the course for > 1-month.[7]

  Results Top

Total 157 NSP TB patients were enrolled in the study. One patient refused to participate in the study. Six patients were not present on the scheduled date of interview to assess knowledge. Hence, we could assess knowledge about TB for 150 NSP TB patients, but sociodemographic data could be collected for 156 patients.

Sociodemographic characteristics of study subjects

Majority (56.7%) of the study subjects were in most reproductive age group that is 20–39 years [Table 1]. Males and female proportion was 67.5% and 32.5%, respectively [Figure 1]. 24.2% (38/156) patients were illiterate [Figure 2], 52.2% were married, 56.7% were employed, and 43.3% (68/156) were unemployed. TB was underlying cause of unemployment for 20.6% (14/68). Median duration of unemployment as 3 months (range = 11 months). Patients from social class V were 37% (56/156) and 23/156 (15%) belonged to social class IV. Total, 53.8% (84/156) were migrants. Median duration of migration was 3 years. 82 (52.8%) were married and out of 8 widowed patients, spouses of three had died due to TB.
Figure 1: Age- and gender-wise distribution of patients

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Figure 2: Educational status of patients

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Table 1: Sociodemographic characteristics of the study subjects

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Different aspects of knowledge regarding tuberculosis Knowledge about infectiousness of tuberculosis

About 75.5% (110/150) did not know type of TB they had is infectious. 29.5% (46/150) knew that TB is infectious. Good knowledge about type of TB was associated with education and socioeconomic status (SES II) (P < 0.0001 and P = 0.017, respectively).

Knowledge about reason behind tuberculosis

About 62.2% (97/150) did not know cause of their disease. 7.1% (11/150) told that cause of TB was smoking, tobacco, alcohol, malnutrition, weakness, DM, tension/worries, environmental pollution, and bad smell. 28.8% (45/150) told that one gets TB due to contact with the person having TB. 1.9% (3/150) told that TB was due to curse. Good knowledge about the reason behind TB was significantly more in males (P = 0.01, odds ratio = 2.246, 95% confidence interval = 1.130–4.466).

Knowledge about spread of tuberculosis

About 2.6% (4/150) cases told that it does not spread. 64.1% (100/150) did not know whether TB spreads or not. 17.3% (27/150) told that it spreads by contact, but did not know exact mode of spread. Only 16% (25/150) cases knew exact mode of spread of TB. Good knowledge about spread of TB was also associated with education and higher SES (P < 0.0001 and P = 0.001), respectively.

Knowledge about curability of tuberculosis

About 32.7% (51/150) did not know whether TB was curable or not by treatment. 8.3% (13/150) told that their disease is not curable. 59% (92/150) cases knew that their disease is curable. Knowledge that TB is curable was associated with education, SES, h/o known cured contacts (P = 0.046, P = 0.002, 0.005).

Knowledge about treatment duration

Surprisingly, 25 (15.9%) cases did not know the duration of their treatment. Thirteen cases knew that duration of the treatment they were taking was < 2 months and all of them were nonadherent. Only 22.3% (35/150) knew correct treatment duration. 25.0% (39/150) knew the importance of regular treatment as for cure [Table 2]. 75.0% (117/150) did not know that regular treatment is necessary for cure. It was associated with illiteracy and leases than 4 years of schooling (P = 0.05) and not associated with any other demographic factor.
Table 2: Treatment durations told by patients

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Treatment adherence and nonadherence of the patients

Overall, 50% (78/156) were treatment adherent, out of them, two were transferred out and four died during the course of treatment before they were interviewed [Figure 3]. Remaining 50% (78/156) were nonadherent to ATT that is they interrupted ATT for > 1-month during the ATT course till any final outcome as per RNTCP. Hence, the analysis is done for 72 treatment adherent and 78 treatment nonadherent patients.
Figure 3: Distribution of cases as per treatment adherence

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Impact of good knowledge regarding tuberculosis and its treatment on anti-tuberculosis treatment adherence

As shown in [Table 3], patients having good knowledge about the infectiousness of TB were 1.764 times more treatment adherent (P < 0.001). Similarly, other aspects of knowledge regarding TB and its treatment like, good knowledge about reasons behind TB, its spread, curability, importance of regular treatment, and treatment duration were significantly associated with ATT adherence.
Table 3: Association of treatment adherence with different aspects of knowledge of TB and its treatment

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  Discussion Top

We assessed baseline knowledge of NSP TB patients about their disease and its treatment which was unfortunately poor.

Salman Khalil reported a good awareness about TB in 88 pulmonary TB patients in the rural area of Uttar Pradesh though 31.8% were illiterate. The majority of their patients believed (95.5%) that TB is curable,[8] as compared to 59n % in our study.

Other study conducted by Saria Tasnim et al. in urban area of Dhaka in 2008 56% of 762 adult TB patients knew the spread of TB correctly as compared to 16% in our study. Majority of them mentioned television as a source of information.[9]

Secondary data analysis of National Family Health Survey III showed 55.5% knew about the correct mode of TB transmission. Listening to radio and knowledge that “TB can be cured” were associated with correct knowledge without misconceptions.[10]

Our study shows that if NSP TB patients have good knowledge about their disease parameters observed as per [Table 3], contribute significantly to their treatment adherence. Improved treatment adherence in turn increases treatment success rate, cure rate, and help to decrease the magnitude of drug resistance. Further, it helps to minimize the spread of infection to the community by improving precautionary measures taken by NSP TB patients.

Freidrick et al. from Zambia reported major factors leading to noncompliance as patients beginning to feel better (45.1% and 38.6%), lack of knowledge on the benefits of completing a course (25.7%).[11] Studies from India also report these factors.[12]

A sound understanding of the knowledge about symptoms and misconceptions about TB and its treatment in the general population is necessary to formulate messages for health education. Time to time surveys about knowledge, attitude, and practice help in impact assessment of the ongoing IEC campaign.[13]

Successful attempts to improve patient adherence depend upon realistic assessment of patients' knowledge about TB and its treatment, clear and effective patient-provider interaction, and developing the trust in therapeutic relationship.[14],[15],[16]

Further studies are needed to study patient-provider interaction and their barriers to improve treatment adherence.

Along with usual methods, at DOTS centers displays using audio-visual aids, ongoing presentations, and short films in patient-friendly language can be helpful to increase knowledge regarding TB. To increase knowledge among the general population is also important as one-third of the population already infected with mycobacterium TB, they carry the risk of developing TB whenever it get a chance to multiply. Their priming to all essential knowledge about TB and its treatment is essential.

Activities like pulse of awareness activities by health care personnel's on TB days may not be sufficient to cover whole population, and these activities should be sustained enough. In India, doctors and health care workers were stated to be the source of the information regarding TB by 50.2% followed by mass media (33.8%), and (34.7%) mentioned interaction with others in the community.[17]

Mass media that is radio and television channels run by government are contributing to increase educational activities regarding TB. However, privatization has lot of impact on utilization of government activities. Some sort of incentives is needed to private channels if they handle the issue properly and effectively.

Lot of measures can be undertaken to improve baseline knowledge of TB in general population like adolescent sensitization, may require revision of school/college curriculum, entertainment channels. Old movies like Sharabiused TB for its devastating outcomes. Now, movie-makers are contributing to social change by creating awareness on medical conditions like blindness, schizophrenia, dyslexia, etc. However, till today, no Sharabi II with a pleasant outcome of TB and its treatment in the main character. Lacking is… intersectoral co-ordination.

Though, results of the study cannot be generalized, the study emphasizes the positive role of knowledge regarding TB and its treatment in ATT adherence, importance of education, and adverse impact of socioeconomic condition of TB patients. Interventional studies are recommended to improve knowledge of TB patients and finding its impact on ATT adherence.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. Global Tuberculosis Control WHO Report 2013. Geneva: World Health Organisation; 2013.  Back to cited text no. 1
WHO. Tuberculosis Control in South-East Asia Region. The Regional Report: 2012, 2013. Available from: http://www.searo.who.int/entity/tb/documents. [Last cited on 2015 May 07].  Back to cited text no. 2
TB Control in India. New Delhi: Directorate General of Health Services Ministry of Health and Family Welfare; 2005.  Back to cited text no. 3
Kulkarni P, Akarte S, Mankeshwar R, Bhawalkar J, Banerjee A, Kulkarni A. Non-adherence of new pulmonary tuberculosis patients to anti-tuberculosis treatment. Ann Med Health Sci Res 2013;3:67-74.  Back to cited text no. 4
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Central TB Division. Directorate General of Health Services MoHaFW: Revised National Tuberculosis Control Programme. Training Module for Community Pharmacists. New Delhi: GOI & Indian Pharmaceutical Association; 2013.  Back to cited text no. 5
Sudan DS, Ramnikaz, Manju, Neetu Swain. Study to evaluate impact of IEC activity on awareness of tuberculosis and RNTCP DOTS among OPD patients around Bathinda area. Indian J Tuberc,2014;61:307-11.  Back to cited text no. 6
Sophia V, Balasangameshwara V, Srikantaramu N. Treatment dynamics and profile of patients under DTP: A prospective cohort study. Indian J Tuberc 1999;46:239-49.  Back to cited text no. 7
Khalil S, Ahmad E, Khan Z, Perwin N. A study of knowledge and awareness regarding pulmonary tuberculosis in patients under treatment for tuberculosis in a rural area of Aligarh – UP. Indian J Community Health 2011;23:93-5.  Back to cited text no. 8
Tasnim S, Rahman A, Hoque FM. Patient's knowledge and attitude towards tuberculosis in an urban setting. Pulm Med 2012;2012:352850.  Back to cited text no. 9
Sreeramareddy CT, Harsha Kumar HN, Arokiasamy JT. Prevalence of self-reported tuberculosis, knowledge about tuberculosis transmission and its determinants among adults in India: results from a nation-wide cross-sectional household survey. BMC Infect Dis 2013;13:16.  Back to cited text no. 10
Kaona FA, Tuba M, Siziya S, Sikaona L. An assessment of factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment. BMC Public Health 2004;4:68.  Back to cited text no. 11
Kulkarni PY, Kulkarni AD, Akarte SV, Bhawalkar JS. Treatment seeking behavior and related delays by pulmonary tuberculosis patients in E-ward of Mumbai Municipal Corporation, India. Int J Med Public Health 2013;3:286-92.  Back to cited text no. 12
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Martin LR, Williams SL, Haskard KB, Dimatteo MR. The challenge of patient adherence. Ther Clin Risk Manag 2005;1:189-99.  Back to cited text no. 13
Menzies R, Rocher I, Vissandjee B. Factors associated with compliance in treatment of tuberculosis. Tuber Lung Dis 1993;74:32-7.  Back to cited text no. 14
Johansson E, Diwan VK, Huong ND, Ahlberg BM. Staff and patient attitudes to tuberculosis and compliance with treatment: An exploratory study in a district in Vietnam. Tuber Lung Dis 1996;77:178-83.  Back to cited text no. 15
Dick J, Schoeman JH. Tuberculosis in the community: 2. The perceptions of members of a tuberculosis health team towards a voluntary health worker programme. Tuber Lung Dis 1996;77:380-3.  Back to cited text no. 16
Malhotra R, Taneja DK, Dhingra VD, Rajpal S, Mehra M. Awareness regarding tuberculosis in a rural population in Delhi. Indian J Community Med 2002;27:62.  Back to cited text no. 17
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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