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Structural Violence, Healthcare Seeking Behavior and Patient-Level Drivers for Defaulting Tuberculosis Treatment in Rural Central India
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A4949 - Structural Violence, Healthcare Seeking Behavior and Patient-Level Drivers for Defaulting Tuberculosis Treatment in Rural Central India
Author Block: B. Seth1, S. Samant2, A. Agarwal3, A. Dhange4, G. Phutke5, P. Jain6, Y. Jain7; 1Internal Medicine, Boston University Medical Center, Boston, MA, United States, 2Community Development, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 3Internal Medicine, Jan Swasthya Sahyog (JSS) and HEAL Initiative Fellow(UCSF), Chattisgarh and San Francisco, CA, United States, 4Family Medicine, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 5Family Medicine Medicine, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 6Internal Medicine, Cambridge Health Alliance, Boston, MA, United States, 7Family Medicine and Pediatrics, Jan Swasthya Sahyog (JSS), Chattisgarh, India.
PURPOSE
India has the largest burden of tuberculosis. Under India's Revised National Tuberculosis Control Program (RNTCP) in 2015, 11% patients defaulted from anti-tuberculosis treatment. Defaulting increases contact exposure and risks development of drug resistance. In 2015, 16% multidrug resistant cases were previously treated. Retreatment success after default RNTCP was 66% in 2014. We sought to explore patients’ perspectives, and barriers to healthcare access, to direct implementation challenges of national tuberculosis programs in rural settings.
METHODS
In the local dialect, we conducted in-depth semi structured interviews of 8 tuberculosis patients, who defaulted (>2 months) initial management, and presented to our tuberculosis clinic or inpatient tuberculosis service. We assessed their experiences, socioeconomic backgrounds, challenges in accessing healthcare. We audiotaped, transcribed, and coded interviews. Two coders identified major themes, and reviewed themes with the team.
RESULTS
Patients who failed the national program driven DOTS (Directly Observed Treatment Shortcourse), took treatment between 2-5 months (of a 6-month course). All patients earned below the poverty line, earning less than $1/day, and were either farmers, laborers or both. Tuberculosis severely affected the functional status of all patients. The mean BMI was 13.2. Most patients sought care from non-physician healers for 2-4 months prior to guideline directed care. All patients had poor understanding of the disease, its presentation, transmission, reasons to seek care and duration of treatment. Two patients reported being diagnosed at home by visiting community based physicians, though did not visit the hospital while symptomatic earlier. Barriers to treatment completion included – feeling better early, intolerable side effects, monetary insecurity to travel to clinics, which were between 20 minutes to 5 hours away, drop in follow up when leaving town in search for work. All patients reported taking loans to travel to clinics. All patients reported no contact from the tuberculosis centers on discontinuing treatment, though this is part of the program. Patients did not report any direct discrimination by the healthcare sector. Patients welcomed a community based treatment approach.
CONCLUSIONS
Interventions to improve utilization rates of tuberculosis treatment will need to address patient-level barriers. Transitioning national programs to community based programs for improved knowledge, screening, effective counselling, health worker home visits for drug delivery, compliance, to decrease travel related out-of-pocket expenditure and to mobilize communities are needed. Addressing patient-level barriers and community based interventions remain key to reduce tuberculosis treatment defaults.
Author Block: B. Seth1, S. Samant2, A. Agarwal3, A. Dhange4, G. Phutke5, P. Jain6, Y. Jain7; 1Internal Medicine, Boston University Medical Center, Boston, MA, United States, 2Community Development, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 3Internal Medicine, Jan Swasthya Sahyog (JSS) and HEAL Initiative Fellow(UCSF), Chattisgarh and San Francisco, CA, United States, 4Family Medicine, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 5Family Medicine Medicine, Jan Swasthya Sahyog (JSS), Chattisgarh, India, 6Internal Medicine, Cambridge Health Alliance, Boston, MA, United States, 7Family Medicine and Pediatrics, Jan Swasthya Sahyog (JSS), Chattisgarh, India.
PURPOSE
India has the largest burden of tuberculosis. Under India's Revised National Tuberculosis Control Program (RNTCP) in 2015, 11% patients defaulted from anti-tuberculosis treatment. Defaulting increases contact exposure and risks development of drug resistance. In 2015, 16% multidrug resistant cases were previously treated. Retreatment success after default RNTCP was 66% in 2014. We sought to explore patients’ perspectives, and barriers to healthcare access, to direct implementation challenges of national tuberculosis programs in rural settings.
METHODS
In the local dialect, we conducted in-depth semi structured interviews of 8 tuberculosis patients, who defaulted (>2 months) initial management, and presented to our tuberculosis clinic or inpatient tuberculosis service. We assessed their experiences, socioeconomic backgrounds, challenges in accessing healthcare. We audiotaped, transcribed, and coded interviews. Two coders identified major themes, and reviewed themes with the team.
RESULTS
Patients who failed the national program driven DOTS (Directly Observed Treatment Shortcourse), took treatment between 2-5 months (of a 6-month course). All patients earned below the poverty line, earning less than $1/day, and were either farmers, laborers or both. Tuberculosis severely affected the functional status of all patients. The mean BMI was 13.2. Most patients sought care from non-physician healers for 2-4 months prior to guideline directed care. All patients had poor understanding of the disease, its presentation, transmission, reasons to seek care and duration of treatment. Two patients reported being diagnosed at home by visiting community based physicians, though did not visit the hospital while symptomatic earlier. Barriers to treatment completion included – feeling better early, intolerable side effects, monetary insecurity to travel to clinics, which were between 20 minutes to 5 hours away, drop in follow up when leaving town in search for work. All patients reported taking loans to travel to clinics. All patients reported no contact from the tuberculosis centers on discontinuing treatment, though this is part of the program. Patients did not report any direct discrimination by the healthcare sector. Patients welcomed a community based treatment approach.
CONCLUSIONS
Interventions to improve utilization rates of tuberculosis treatment will need to address patient-level barriers. Transitioning national programs to community based programs for improved knowledge, screening, effective counselling, health worker home visits for drug delivery, compliance, to decrease travel related out-of-pocket expenditure and to mobilize communities are needed. Addressing patient-level barriers and community based interventions remain key to reduce tuberculosis treatment defaults.
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