Jiangsu Provincial Center for Disease Prevention and Control, Nanjing, PR China.
BMC Health Serv Res. 2009 Sep 18;9:169. doi: 10.1186/1472-6963-9-169.
Tuberculosis (TB) patients have difficulty following a long-term treatment regimen. Efforts to improve treatment outcomes require better understanding of adherence as a complex behavioral issue and of the particular barriers to and facilitators of patient adherence.
This study was carried out in Jiangsu Province of China with both quantitative and qualitative approaches. For the quantitative study, 780 sputum-smear positive TB patients consecutively registered since 2006 in 13 counties (districts) were queried with a structured questionnaire. Patients who had missed 10% of their total prescribed doses of TB drugs were deemed as non-adherent. Risks for non-adherence were estimated by computing odds ratios (ORs) and their 95% confidence intervals (95% CIs) using a logistic regression model. We also invited 20 TB patients and 10 local health workers for in-depth interviews. We then used content analysis based on this qualitative study to explore factors associated with non-adherence.
The proportion of non-adherence among 670 patients was 12.2%. Univariate analysis showed that patients, who were illiterate, divorced/widowed, lacked health insurance and were migrants, were more likely to be non-adherent. The crude ORs(95%CIs) were 2.38(1.37-4.13), 2.42(1.30-4.52), 1.89(1.07-3.32) and 1.98(1.03-3.83), respectively. The risk of non-adherence was lower among patients whose treatment was given under direct observation by village doctors or regular home visits by health workers, with ORs (95% CIs) of 0.19(0.10-0.36) and 0.23(0.10-0.51), respectively. In multivariate analysis, factors associated with non-adherence included illiteracy (OR: 2.42; 95% CI: 1.25-4.67) and direct observation by village doctors (OR: 0.23; 95% CI: 0.11-0.45). The in-depth interviews indicated that financial burdens and extra medical expenditures, adverse drug reactions, and social stigma were additional potential factors accounted for non-adherence.
More importance should be given to treatment adherence under the current TB control program. Heavy financial burdens, lack of social support, adverse drug reactions and personal factors are associated with non-adherence. Direct observation and regular home visits by health workers appear to reduce the risk of non-adherence. More patient-centered interventions and greater attention to structural barriers are needed to improve treatment adherence.
结核病（TB）患者难以遵循长期治疗方案。为了改善治疗效果，需要更好地理解依从性作为一个复杂的行为问题，以及患者依从性的特定障碍和促进因素。
本研究在中国江苏省采用定量和定性方法进行。对于定量研究，自 2006 年以来，在 13 个县（区）连续登记的 780 例痰涂片阳性结核病患者接受了结构化问卷查询。总规定剂量药物的 10%漏服被视为不依从。使用 logistic 回归模型计算比值比（OR）及其 95%置信区间（95%CI）来估计不依从的风险。我们还邀请了 20 名结核病患者和 10 名当地卫生工作者进行深入访谈。然后，我们使用基于这项定性研究的内容分析来探讨与不依从相关的因素。
670 名患者中不依从的比例为 12.2%。单因素分析显示，文化程度低、离婚/丧偶、缺乏医疗保险和流动人口的患者更有可能不依从。未经调整的 OR（95%CI）分别为 2.38（1.37-4.13）、2.42（1.30-4.52）、1.89（1.07-3.32）和 1.98（1.03-3.83）。由乡村医生直接观察或卫生工作者定期家访提供治疗的患者，不依从的风险较低，OR（95%CI）分别为 0.19（0.10-0.36）和 0.23（0.10-0.51）。多因素分析显示，与不依从相关的因素包括文化程度低（OR：2.42；95%CI：1.25-4.67）和乡村医生直接观察（OR：0.23；95%CI：0.11-0.45）。深入访谈表明，经济负担和额外医疗支出、药物不良反应和社会耻辱感是导致不依从的其他潜在因素。
在当前的结核病控制规划中，应更加重视治疗依从性。沉重的经济负担、缺乏社会支持、药物不良反应和个人因素与不依从有关。乡村医生的直接观察和定期家访似乎降低了不依从的风险。需要更多以患者为中心的干预措施，并更加关注结构性障碍，以提高治疗依从性。
