Several factors can influence adherence, including barriers related to the patient, the treatment or the therapeutic environment. While it is not always feasible to address all these factors, at the very least it is possible to control the treatment and therapeutic environment-related factors.
13.3.1 Patient-related factors
A discussion should be held with the patient prior to treatment initiation and then during every contact they have with the healthcare team. The objective is to identify and anticipate barriers to treatment adherence. Barriers may include:
- Socioeconomic factors (work and home responsibilities, treatment-related costs, decreased income, etc.).
- Psychological factors (feelings of shame, fear of stigma or marginalisation, uncertainty about the future, conceptions about the disease and its treatment, etc.).
- Physical or mental disability.
- Lack of knowledge about the disease and treatment.
- Perception of the disease and treatment (a patient might abandon treatment due to improvement or absence of improvement, a negative experience with a previous treatment, etc.).
Solutions depend on the context and the patient’s problem, and therefore should be identified on a case-by-case basis.
13.3.2 Treatment-related factors
- Simplicity of treatment improves adherence. The use of FDC simplifies the treatment by reducing the number of tablets. In addition, FDC prevents omission of one or more prescribed TB drugs.
- Adverse effects may lead patients to interrupt their treatment, so these should be detected and managed promptly.
13.3.3 Factors related to the therapeutic environment
- To ensure the widest possible access to treatment, TB diagnosis, monitoring and treatment (including TB drugs, drugs for adverse effects and co-morbidities, mental health care) should be provided free of charge.
- The relationship between patients and healthcare workers influences adherence. If patients have confidence in healthcare staff, they are more likely to follow recommendations and engage with the treatment process. Patients are also more likely to bring questions and concerns to the attention of healthcare staff. The same applies to the relationship with treatment supporters.
- In health facilities, the way in which patients are received is essential. Confidentiality of personal, medical, administrative and social information should be assured. Waiting times for diagnosis or follow-up visits should be reasonable.
- Drug supply management must be rigorous. Shortages can lead to treatment interruption and negatively impact adherence (patients waste time in unnecessary travel and lose confidence in the health facility).
- The proximity of drug distribution sites limits the number of patients who abandon due to transportation problems. To anticipate potential problems, give the patients a few extra days of treatment in case they are unable to come to get their drugs as scheduled.
- For the co-management of TB and HIV infection, patients should receive TB and HIV treatment at the same time and in the same place ("one-stop service"). This reduces the number of visits and decreases waiting times, which results in greater patient satisfaction and improved treatment outcomes. Co-management of other co-morbidities (e.g. diabetes, hypertension) should, when possible, use the same approach.
- Hospitalisation should be limited to patients with clinical conditions requiring hospital level care. If hospitalisation is necessary, accommodation (comfort, food, heating, etc.) should be adequate. With the exception of end-of-life patients, the duration of stay should be as short as possible and patients should be discharged as soon as their clinical condition allows.