Assessing key influence factors on patient adherence and compliance for the implementation of a tuberculosis control program in Lusaka, Zambia

Abstract

Background: In Zambia, tuberculosis (TB) remains amajor issue despite the availability of free anti-TB drugs and sensitization programs. Based on analysis of TB perceptions and health care seeking behaviour of TB patients, this case study demonstrates how cultural, socio-economic, and structural factors influencing patient adherence and compliance impair successful implementation of the TB control program. Methods & Materials: TB patient recruitment took place at the Kanyama clinic in Lusaka, Zambia. A combination of quantitative and qualitativemethodswere used, including 300 structured interviews at the clinic, various in-depth interviews with 30 patients at home, 6 focus group discussions, and participant observation. Additionally, 10 biomedical health care providers and 20 traditional/spiritual healers were interviewed. Results: Many TB patients (some repeatedly) relapsed (around 40%) and HIV co-infection rate was around 50%. Almost all patients did a VCT and about three quarters of TB-HIV patients were on ARV’s. Etiological principles were promiscuity (due to association with HIV), sleepingwithwomenwho aborted (the spirit of Kapopo) or on their menses, eating food with salt added by a woman on her menses, witchcraft, drinking beer, smoking, and inheritance (family TB).Meanwhile, the biomedical explanation about TB bacilli and its airborne nature was recognised by most patients. Poverty was problematic causing around three quarters of patients struggling with foodprovision.Aminorityofpatients combineddifferenthealing methods, mostly pharmacy or spiritual healing, some opted for traditional healing. Abandoning treatment or poor compliancewas rare but frequently related to alcohol consumption. Patient delay remained a challenge partly caused by stigma, long queues at the clinic, and preference for private clinics. Conclusion: There is a need to enhance cooperation between hospitals, patients, traditional/spiritual healers and communities to stimulate patient adherence. Employment of volunteers at the clinic could enhance already existing programs like patient follow up, (family) sensitization, and counselling. Discussion programs should be organised aiming at both educating and changing attitudes considering stigma and alcohol-consumption. It is necessary to eliminate structural obstacles like long queues at the clinic and to organise a food aid program for most needed patients in order to cope with TB medication.