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      Factors Influencing Medication Nonadherence to Pulmonary Tuberculosis Treatment in Tibet, China: A Qualitative Study from the Patient Perspective


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          Medication nonadherence is one of the most significant obstacles to tuberculosis (TB) control worldwide. Identification of the factors associated with medication nonadherence is important. However, few related studies have been carried out in Tibet. This study aimed to explore factors influencing medication nonadherence to pulmonary TB (PTB) treatment in Tibet, China, from the patient perspective.

          Patients and Methods

          In this qualitative study, seventeen PTB patients in Tibet were recruited by purposive and maximum variation sampling methods. In-depth semistructured interviews were conducted to collect data on factors influencing medication nonadherence, and Colaizzi’s seven-step method was used to analyze the data.


          The medication nonadherence of PTB patients in Tibet was influenced by one or a combination of the following four factors. First, patient-related factors included a lack of knowledge of PTB treatment, poor self-management capability, poor self-regulation capability and misperception of health condition. Second, a medication-related factor was medication side effects. Third, health service-related factors included the poor treatment skills of doctors in primary hospitals and a lack of directly observed treatment (DOT). Last, sociocultural factors included the effect of traditional Tibetan medicine, lack of family member support and discrimination.


          Multiple interplaying factors influenced medication nonadherence during PTB treatment in Tibet, and the main influencing factors were a lack of knowledge about PTB treatment, poor self-management capability, and the effect of traditional Tibetan medicine. TB health workers in Tibet should provide permanently viewable PTB treatment knowledge materials to PTB patients when oral health education is conducted, find feasible alternative strategies to DOT and establish links to traditional Tibetan medicine hospitals.

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          Most cited references 29

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          Tuberculosis prevalence in China, 1990-2010; a longitudinal analysis of national survey data.

          China scaled up a tuberculosis control programme (based on the directly observed treatment, short-course [DOTS] strategy) to cover half the population during the 1990s, and to the entire population after 2000. We assessed the effect of the programme. In this longitudinal analysis, we compared data from three national tuberculosis prevalence surveys done in 1990, 2000, and 2010. The 2010 survey screened 252,940 eligible individuals aged 15 years and older at 176 investigation points, chosen by stratified random sampling from all 31 mainland provinces. All individuals had chest radiographs taken. Those with abnormal radiographs, persistent cough, or both, were classified as having suspected tuberculosis. Tuberculosis was diagnosed by chest radiograph, sputum-smear microscopy, and culture. Trained staff interviewed each patient with tuberculosis. The 1990 and 2000 surveys were reanalysed and compared with the 2010 survey. From 1990 to 2010, the prevalence of smear-positive tuberculosis decreased from 170 cases (95% CI 166-174) to 59 cases (49-72) per 100,000 population. During the 1990s, smear-positive prevalence fell only in the provinces with the DOTS programme; after 2000, prevalence decreased in all provinces. The percentage reduction in smear-positive prevalence was greater for the decade after 2000 than the decade before (57% vs 19%; p<0.0001). 70% of the total reduction in smear-positive prevalence (78 of 111 cases per 100,000 population) occurred after 2000. Of these cases, 68 (87%) were in known cases-ie, cases diagnosed with tuberculosis before the survey. Of the known cases, the proportion treated by the public health system (using the DOTS strategy) increased from 59 (15%) of 370 cases in 2000 to 79 (66%) of 123 cases in 2010, contributing to reduced proportions of treatment default (from 163 [43%] of 370 cases to 35 [22%] of 123 cases) and retreatment cases (from 312 [84%] of 374 cases to 48 [31%] of 137 cases; both p<0.0001). In 20 years, China more than halved its tuberculosis prevalence. Marked improvement in tuberculosis treatment, driven by a major shift in treatment from hospitals to the public health centres (that implemented the DOTS strategy) was largely responsible for this epidemiological effect. Chinese Ministry of Health. Copyright © 2014 Elsevier Ltd. All rights reserved.
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            Effectiveness of Electronic Reminders to Improve Medication Adherence in Tuberculosis Patients: A Cluster-Randomised Trial

            Background Mobile text messaging and medication monitors (medication monitor boxes) have the potential to improve adherence to tuberculosis (TB) treatment and reduce the need for directly observed treatment (DOT), but to our knowledge they have not been properly evaluated in TB patients. We assessed the effectiveness of text messaging and medication monitors to improve medication adherence in TB patients. Methods and Findings In a pragmatic cluster-randomised trial, 36 districts/counties (each with at least 300 active pulmonary TB patients registered in 2009) within the provinces of Heilongjiang, Jiangsu, Hunan, and Chongqing, China, were randomised using stratification and restriction to one of four case-management approaches in which patients received reminders via text messages, a medication monitor, combined, or neither (control). Patients in the intervention arms received reminders to take their drugs and reminders for monthly follow-up visits, and the managing doctor was recommended to switch patients with adherence problems to more intensive management or DOT. In all arms, patients took medications out of a medication monitor box, which recorded when the box was opened, but the box gave reminders only in the medication monitor and combined arms. Patients were followed up for 6 mo. The primary endpoint was the percentage of patient-months on TB treatment where at least 20% of doses were missed as measured by pill count and failure to open the medication monitor box. Secondary endpoints included additional adherence and standard treatment outcome measures. Interventions were not masked to study staff and patients. From 1 June 2011 to 7 March 2012, 4,292 new pulmonary TB patients were enrolled across the 36 clusters. A total of 119 patients (by arm: 33 control, 33 text messaging, 23 medication monitor, 30 combined) withdrew from the study in the first month because they were reassessed as not having TB by their managing doctor (61 patients) or were switched to a different treatment model because of hospitalisation or travel (58 patients), leaving 4,173 TB patients (by arm: 1,104 control, 1,008 text messaging, 997 medication monitor, 1,064 combined). The cluster geometric mean of the percentage of patient-months on TB treatment where at least 20% of doses were missed was 29.9% in the control arm; in comparison, this percentage was 27.3% in the text messaging arm (adjusted mean ratio [aMR] 0.94, 95% CI 0.71, 1.24), 17.0% in the medication monitor arm (aMR 0.58, 95% CI 0.42, 0.79), and 13.9% in the combined arm (aMR 0.49, 95% CI 0.27, 0.88). Patient loss to follow-up was lower in the text messaging arm than the control arm (aMR 0.42, 95% CI 0.18–0.98). Equipment malfunction or operation error was reported in all study arms. Analyses separating patients with and without medication monitor problems did not change the results. Initiation of intensive management was underutilised. Conclusions This study is the first to our knowledge to utilise a randomised trial design to demonstrate the effectiveness of a medication monitor to improve medication adherence in TB patients. Reminders from medication monitors improved medication adherence in TB patients, but text messaging reminders did not. In a setting such as China where universal use of DOT is not feasible, innovative approaches to support patients in adhering to TB treatment, such as this, are needed. Trial Registration Current Controlled Trials, ISRCTN46846388
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              Tuberculosis is still a leading cause of death in low-income and middle-income countries, especially those of sub-Saharan Africa where tuberculosis is an epidemic because of the increased susceptibility conferred by HIV infection. The effectiveness of the Bacille Calmette Guérin (BCG) vaccine is partial, and that of treatment of latent tuberculosis is unclear in high-incidence settings. The routine diagnostic methods that are used in many parts of the world are still very similar to those used 100 years ago. Multidrug treatment, within the context of structured, directly observed therapy, is a cost-effective control strategy. Nevertheless, the duration of treatment needed reduces its effectiveness, as does the emergence of multidrug-resistant and extensively drug-resistant disease; the latter has recently become widespread. The rapid expansion of basic, clinical, and operational research, in addition to increasing knowledge of tuberculosis, is providing new diagnostic, treatment, and preventive measures. The challenge is to apply these advances to the populations most at risk. The development of a comprehensive worldwide plan to stop tuberculosis might facilitate this process by coordinating the work of health agencies. However, massive effort, political will, and resources are needed for this plan to succeed.

                Author and article information

                Patient Prefer Adherence
                Patient Prefer Adherence
                Patient preference and adherence
                10 July 2020
                : 14
                : 1149-1158
                [1 ]School of Medicine, Xizang Minzu University , Xianyang, Shaanxi, People’s Republic of China
                [2 ]Department of Pulmonary, The Third People’s Hospital of Tibet Autonomous Region , Lhasa, Tibet, People’s Republic of China
                Author notes
                Correspondence: Jinjing Zhang School of Medicine, Xizang Minzu University , #6 Wenhui East Road, Xianyang712082, Shaanxi, People’s Republic of ChinaTel +86 186 9100 8710Fax +86 029 3375 5433 Email jinjingzhang@xzmu.edu.cn

                These authors contributed equally to this work

                © 2020 Zhang et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 1, Tables: 2, References: 36, Pages: 10
                Funded by: the Humanities and Social Sciences Research Foundation for Tibet Autonomous Region Universities
                Funded by: the Tibet Qin Himalaya Young Backbone Teacher Foundation of Xizang Minzu University
                This study was funded by the Humanities and Social Sciences Research Foundation for Tibet Autonomous Region Universities (SK2019-24), as well as the Tibet Qin Himalaya Young Backbone Teacher Foundation of Xizang Minzu University. The sponsors have not participated in this study.
                Original Research


                pulmonary tuberculosis, medication compliance, in-depth interview, influencing factor


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