The bi-variable binary logistic regression analysis showed that patient age, educational level, distance to the health facility, provider-patient relationship, patient knowledge on TB treatment, and family wealth index were associated with adherence to TB treatment during the continuation phase.
Whereas, in the multivariable binary logistic regression analysis, patients' educational level, provider-patient relationship, patient knowledge on TB treatment, and family wealth index were associated with the outcome variable. Secondary level educated patients were four times more likely to adhere to TB treatment as compared to non-educated patients (AOR = 4.138, 95% CI; 1.594–10.74). Similarly, patients who reported good provider-patient relationships were 2 times more likely to adhere to the treatment than their counterparts, with (AOR = 1.863, 95% CI; 1.014–3.423). Those who have good knowledge of TB treatment were also more likely to adhere (AOR = 1.845, 95% CI; 1.012–3.362). Patients with middle family wealth were 3 times more likely to adhere than patients with poor family wealth (AOR = 2.646, 95% CI; 1.360–5.148) (Table 3).
Table 3
Factors associated with adherence to TB medication and pill refilling during continuation phase in Northwest Ethiopia (n=307)
Variables
|
Adherent
|
COR(95%CI)
|
AOR(95%CI)
|
Yes
|
No
|
Patient age
|
|
|
|
|
|
24years and below
|
58
|
26
|
2.317 (1.139-4.712)*
|
1.533 (.642-3.661)
|
|
25-34 years
|
81
|
29
|
2.901 (1.461-5.757)*
|
2.123 (.937-4.813)
|
|
35-44 years
|
32
|
28
|
1.187 (.566-2.487)
|
.879 (.378-2.043)
|
|
45+ years
|
26
|
27
|
1
|
1
|
Sex
|
|
|
|
|
|
Male
|
113
|
65
|
1
|
1
|
|
Female
|
84
|
45
|
1.074 (.669-1.724)
|
1.251 (.707-2.214)
|
Residence
|
|
|
|
|
|
Urban
|
146
|
74
|
1.393 (.836-2.320)
|
.764 (.374-1.559)
|
|
Rural
|
51
|
36
|
1
|
1
|
Educational level
|
|
|
|
|
|
No education
|
53
|
48
|
1
|
1
|
|
Informal education
|
20
|
17
|
1.065 (.501-2.268)
|
.729 (.299-1.773)
|
|
Primary
|
45
|
28
|
1.456 (.789-2.685)
|
1.057 (.501-2.231)
|
|
Secondary
|
46
|
10
|
4.166 (1.895-9.157)*
|
4.138 (1.594-10.74)*
|
|
Higher
|
33
|
7
|
4.27 (1.728-10.55)*
|
2.795 (.970-8.052)
|
Distance to the health facility
|
|
|
|
|
|
Less than 5km
|
72
|
156
|
2.708 (1.206-6.081)*
|
2.275 (.877-5.903)
|
|
5-10km
|
23
|
29
|
1.576 (.618-4.018)*
|
1.672 (.589-4.746)
|
|
Greater than 10km
|
15
|
12
|
1
|
1
|
Treatment supporter assigned
|
|
|
|
|
|
Yes
|
74
|
123
|
1
|
1
|
|
No
|
36
|
73
|
1.22 (.746-1.996)
|
1.375 (.769-2.457)
|
Disclosed TB status to family
|
|
|
|
|
|
Yes
|
105
|
189
|
1.125 (.359-3.527)
|
.744 (.191-2.902)
|
|
No
|
5
|
8
|
1
|
1
|
Provider-patient relationship
|
|
|
|
|
|
Good
|
112
|
45
|
1.903 (1.186-3.055)*
|
1.863 (1.014-3.423)*
|
|
Poor
|
85
|
65
|
1
|
1
|
Knowledge on TB treatment
|
|
|
|
|
|
Good
|
157
|
72
|
2.072 (1.226-3.5)*
|
1.845 (1.012-3.362)*
|
|
Poor
|
40
|
38
|
1
|
1
|
Attitude on TB treatment
|
|
|
|
|
|
Favorable
|
121
|
59
|
1.376 (.858-2.206)
|
1.272 (.702-2.305)
|
|
Unfavorable
|
76
|
51
|
1
|
|
Wealth index
|
|
|
|
|
|
Poor
|
54
|
49
|
1
|
1
|
|
Middle
|
71
|
31
|
2.078 (1.173-3.683)*
|
2.646 (1.360-5.148)*
|
|
Rich
|
72
|
30
|
2.178 (1.225-3.871)*
|
1.949 (.957-3.968)
|
*p-value less than 0.05
Patients who were non-adherent to their TB medication were asked for their reasons for failure to treatment adherence. More than half 58% (n = 110, non-adherent participants) reported forgetfulness to daily medication, 17.3% reported traveling away from home without pills, 8.2% and 5.5% were due to feeling sick and fearing side effects of the drugs, respectively (Fig. 1).
TB focal care providers were also asked for their perspectives about contributing factors for non-adherence to TB treatment. Poor communication and relationship with their patients, transportation and related costs for pill refilling, relapsing of the disease, political unrest, and poor treatment support at the community were found major contributing factors for non-adherence to TB treatment during the continuation phase.
All respondents agreed that good communication and relationship was essential for patient adherence to TB medications. However, about half (4/9) of participants reported that their communication with patients decline as the patients shifted from the intensive phase (facility-based treatment) to the continuation phase. Another male TB focal care provider also added that:
During the continuation phase, we do not have daily contact with patients as we do on intensive phase. Even, weekly attendance was not easy. Some patients did not come, they send their supporter/family member to the clinic for refilling, and they were busy with family matters, social events like a funeral.
In the key-informant interview, the majority of TB focal providers also exemplified that patients with low income tend to miss and/or interrupt refilling due to transportation and related costs. Besides, relapse cases tend to default treatments. A female TB focal care provider replied that
“TB patients on continuation phase often miss refilling and from my experience, their reasons are mainly related to transportation cost and unintended social events”.
Participants also mentioned that relapsing cases tend to lost-to-follow-up. Another female focal care provider added that:
"This year alone we lost two patients due to relapse of the case [TB]. One female insisted not to take the pills anymore and decided to go to Monastery. Similarly, one male patient lost from treatment follow-up…"
Political unrest and security problems were among the challenges for the patient, the care providers, and central drug suppliers. A male TB focal care provider replied that
Our community was victimized with frequent political turmoil and security problems which results in lost-to-follow due to massive displacement, migration of care-providers, and interruption of drug supply from the center.
Respondents were also asked their opinion on whether the assigned treatment supporters were helpful during the continuation treatment phase. Many participants replied that they were not helpful as intended, and (2/9) reported as helpful. The problem begins with assigning treatment supporters. A male TB focal care provider reported that:
"During assigning treatment supporters, patients often choose educated relatives without considering the distance away from their home: mostly, they choose their relatives in urban while the patient living in rural."
In addition, the commitment of treatment supporters was confronted by their income level and their prior commitments as reported by the respondents. A male TB focal care provider mentioned that:
Treatment supporters very rarely accompany patients during refilling, they mention transportation cost, own family, and social commitments.
Another male TB focal care provider also added that:
"During the continuation phase, we assign treatment supporters but in practice, most did not follow and most focal providers lack skills to influence patients to take their pills at home"