13.2 Factors that influence adherence

See reference 2

There are several factors that can influence adherence, being barriers related to the patient, the treatment or the therapeutic environment. While it is not always possible to control all of these factors —particularly those related to the patient— it is possible to at least control the treatment and therapeutic environment-related factors.

13.2.1 Patient-related factors

– Socioeconomic factors such as having a job, a home, family or other support, being stigmatized or marginalized;
– Psychological factors such as feelings of discouragement;
– Understanding and perception of the disease and treatment: a patient might continue or abandon treatment because s/he sees, or does not see, improvement. S/he might also have trouble taking an active part in treatment if s/he attributes the illness to supernatural causes, etc.

Personal difficulties should be discussed at patient visits. Solutions will depend on the context and the patient’s problem, and need to be found on a case-by-case basis.

13.2.2 Treatment-related factors

– Simplicity of treatment improves adherence. The use of fixed-dose combinations (FDCs) simplifies the treatment by reducing the number of tablets. In addition, it also prevents the patient from removing one or more medications from the treatment.
– Adverse effects are often the reason why patients interrupt their treatment and must be quickly detected and adequately managed.

For drug-resistant TB (DR-TB), the number of tablets to be taken every day, the lack of FDCs, and the frequency and severity of adverse reactions make daily accompaniment necessary (see Section 13.3).

13.2.3 Factors related to the therapeutic environment

– Patients’ welcome is essential. Waiting times at clinics should be reasonable. For hospitalized patients, accommodations (comfort, food, heating, etc.) should be adequate.

– The proximity of drug distribution centres limits the number of patients who abandon due to transportation problems.

– The relationship between the health care worker and the patient influences the adherence. If a patient trusts or has confidence in his/her health care worker, s/he is more likely to follow instructions and advice and to collaborate with the health care worker. Patients may also be more likely to bring questions and concerns to the health care worker's attention.

– Hospitalization should be limited. Most cases can be treated as outpatients. If hospitalisation is required, the duration of stay should be as short as possible. Patients should be discharged as soon as their clinical condition allows.

– Free care (visits, laboratory tests and treatment, including those relating to adverse effects) limits the number of patients who abandon for financial reasons.

– The co-management of HIV infection and TB requires coordination between the TB and HIV/AIDS programmes at all levels. Systems that set up a “one-stop service”, where patients receive both TB and HIV care, reduces the number of visits and decreases waiting times resulting in higher patient satisfaction and better results.

– Coordination for other diseases, like diabetes and hypertension, can also take place in the same clinic to decrease the burden on the patient.

– Drug supply management must be rigorous. It is essential to avoid shortages, which can lead to treatment interruption and negatively impact adherence (patients waste time in pointless travel, lose confidence in the clinic, etc.).

– To anticipate possible problems, give the patient a few extra days’ worth of treatment, in case s/he cannot come get his/her drugs on the scheduled date.