November 1988, Volume 38, Issue 11

Original Article


Ghazala Ansari  ( Nazimabad Chest Clinic, Aga Khan University, Karachi. )
Tufail Q. Shaikh  ( Communjty Health Services, Aga Khan University, Karachi. )
Majeed Memon  ( Department of Medicine, Aga Khan University, Karachi. )


An attempt was made to estimate compliance with antituberculosis chemotherapy by measuring the treatment completion rate. At the end of one year follow-up of 806 newly diagnosed patients in an urban outpatient setting, only 58 (7%) came to collect their supplies of medicines for the required duration. Such a high drop-out rate (93%) is very alarming, as it wilt not only leave a large number of patients uncured, but provides constant sources of infection in the community.
The findings indicate that besides taking established measures for improving compliance, such as to understand the specific reasons for noncompliance
short term chemotherapies, there is an urgent need in our patient population (JPMA 38:, 1988).


The problem of compliance to antituber­culosis chemotherapy is world-wide. This problem, however is of greater concern in developing coun­tries, including Pakistan, where tuberculosis is highly prevalent and health care resources are very limited. The goal of a tuberculosis control programme is not only to provide adequate facilities for the treatment but also to ensure that the maximum number of the patients comply with treatment for the recommended dosage and duration.1-2
Non-compliance in its various forms may lead to drug resistance, continuing transmission of infection, treatment failure and unacceptable levels of mortality. Inadequate control programs simply keep patients alive, shedding tubercie bacilli longer, thereby adding to the infections reservoir in the community. 3-4
The objective of the present study was to estimate compliance with antituberculosis chemotherapy by measuring treatment com­pletion rates. That is, to document the number of cases who show up regularly at pre-determined dates to receive their supply of drugs for the required duration of 12 months. However, there is no guarantee that the drugs handed out will actually be taken. Neither, that the patients who have completed the full treatment, necessarily reflect the number of cases cured.


The study was conducted in the Nazimabad Chest Clinic which, as part of the governments tuberculosis control program, is devoted to diag­nose and treat tuberculosis patients on an out­patient’s basis. The daily patient census at the clinic is between 250 to 300.
Eight hundred and six newly diagnosed tuberculosis patients irrespective of extent of disease and excluding children and visitors from outside the city between October 1, 1981, and September 30, 1982 were included in the study.
The criteria for diagnosis were clinical, bacteriological and radiological. The ages ranged from 16-72 years, and male female ratio was 2: 1 (536 males, 270 females). Most of them were from low socio-economic strata but majority were able to read and write.
On inclusion in the study, all patients were seen by the treating physician and a lady health visitor (LHV) separately. The patient was briefed about the nature of illness, precautions to be taken, the total duration of the drug therapy and consequences of defaulting from treatment and the dosage and time of medications. All the instructions were in Urdu which was the most commonly understood language.
Patients were followed for 12 months and were checked by the regularity of attendence to collect supply of medicines. On first couple of follow up visits the presence of the patient was required, but subsequently a close relative was also allowed to collect the medicines, which were sup­plied free of cost for 15 days on each visit. The patients also carried a reminder card stating the date of attendance and next appointment. The card also contained instructions in Urdu for taking medicines, and there appeared little dif­ficulty in understanding these instiuctions.
Treatment was on ambulatory basis, consi­sting of standard regimens of streptomycin, !INH, Ethambutol or Streptomycin, INH and Thioce­tazone.
If there was some delay in receiving of medicines, the patient was counselled by a LHV and was helped to overcome the problem so as to improve compliance. A reminder was sent if he/she did not show up within two weeks of the renewal date; followed by 2nd and 3rd reminders at the intervals of four and eight weeks from the first one. A patient defaulting beyond three months was considered a treatment dropout.


Table shows the quarterly loss of the patients from the study. Of 806 patients only 58 completed their full 12-month duration of the treatment. The dropout rates were 35% in the first quarter, followed by 19% in each of the remaining three quarters. Thus, 93% of the patients failed to complete the one year treat­ment.

TABLE Loss of Patients during the 12-Month follow-up Period.
The quarterly dropout rate, expressed as a percentage loss from the total number of patients present at the beginning of that quarter, demons­trated increasing rates from the 3rd quarter. The final quarter rate was the highest at 73% while the lowest (30%) was in the 2nd quarter (Figure 1 and 2).


1. IUAT/WHO Study Group Tuberculosis Control. WHO Tech. Rep. Set., 1982; 671.
2. Toman, K. Tuberculosis case-finding and chemo­therapy; questions and answers. Geneva, World Health Organization, 1979.
3. Chaulet, P. Compliance with antituberculosis chemotherapy in developing countries. Tubercie, 1987; 68:19.
4. Reichman, L.B. Compliancein developed nations. Tubercie, 1987; 68:25.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: