Factors influencing knowledge on completion of treatment among TB patients under directly observed treatment strategy, in selected health facilities in Embu County, Kenya

Introduction The World Health Organization (WHO) promotes the Directly Observed Treatment (DOT) strategy as the standard to increase adherence to Tuberculosis (TB) medication. However, cases of retreatment and Multi Drug Resistant continue to be reported in many parts of Kenya. This study sought to determine the factors influencing the completion of tuberculosis medication among TB patients in Embu County, Kenya. Methods A descriptive cross-sectional study was conducted on a population of tuberculosis patients under DOT attending selected TB treatment clinics in Embu County, in Kenya. One hundred and forty TB patients interviewed within a period of 3 months. Data were analyzed using SPSS version 17.0 and included Bivariate and Multivariate Analysis. The level of significance was p≤ 0.05. Results The male and female participants were 61.4% and 38.6% respectively. The mean age of the respondents was 35±31.34-39.3 years. For the majority (52%) of the participants, the highest level of education was primary education. The unemployed participants formed the highest number of the respondent in the study (73%). The majorities (91.4%0) of the respondents were under the home-based DOT strategy (91.4%, 95% C.I: 85.5-95.5). Bivariate analysis using Chi-square showed that the level of education (p=0.003), patients feeling uncomfortable during supervision (p=0.01), and knowledge regarding the frequency of taking medication (p=0.004) were all significantly associated with knowledge regarding the importance of completion of medication. However, none of these factors was significant after multivariate analysis. Conclusion Most participants did not know the importance of completion of medication. TB programs should come up with better ways to educate TB patients on the importance of supervision and treatment completion during the treatment of TB. The education programs should focus on influencing the attitudes of patients and creating awareness about the importance of treatment completion. The TB programs should be designed towards eliminating the factors influencing the completion of TB medication.


Introduction
The socioeconomic cost of TB is particularly high in developing countries where low quality of life contributes to the spread of TB [1]. In 2013, nearly 2 million people died from TB globally [2]. The Directly Observed Treatment Short-course (DOTS) remains the World Health Organisation standard of care for drug susceptible tuberculosis across the world. However, critics of the DOTS allege that it has no benefits over the alternatives, such as Self-Administered Therapy (SAT) [3]. Under the DOTS program, family members and/or friends observe TB patients taking their medications for the first two months of treatment. The following 4-6 months, patients usually administer their anti-TB drugs in a component called DOT [1]. During the period of unsupervised treatment, some patients default on treatment leading to treatment failure rates, which in turn leads to the spread of TB further and the development of MDR. The Directly Observed Therapy has generated controversies concerning its efficacy in promoting treatment adherence [4]. Conflicting outcomes have been reported about treatment completion under DOT [4].

Study site
The study was conducted in TB treatment health facilities in Embu County, Kenya. The selected facilities included Runyenjes subdistrict hospital, Nembure health center, Kianjokoma health center, and Kibugu health center.

Study design
A descriptive cross-sectional study was used.

Study population
The study targeted tuberculosis patients over 18 years of age, under treatment in the selected health facilities.

Sample size determination and sampling
The number of health facilities undertaking TB treatment in Embu County was identified from government records. From these health facilities, random selection of the health facilities included in the study was done. For the selected health facilities, a sampling frame was created using the TB patient records, and stratified random sampling was then used to select 140 patients, under treatment, who were interviewed in the study. The selection and interview of the participants took place within 3 months. The study was conducted between May and July 2011.

Data collection and analysis
Data were obtained from the respondents using semi-structured questionnaires and entered into to Microsoft Excel for cleaning, coding, and validation. The data were then transferred to the Statistical Package for Social Science (SPSS) for Windows version 17.0 for statistical analysis. Analysis of descriptive statistics, bivariate analysis using Chi-square test, and multivariate logistic regression with a significant level of p≤0.05 was done. Multivariate analysis using Binary Logistic regression was done for those values, significant at the bivariate level.

Ethical considerations
The study was completed according to the revised Helsinki Declaration [5]. Ethical approval was obtained from Kenya Medical Research (KEMRI) Ethical Research Committee. Authorization to conduct the study in the local health facilitated was obtained from the Provincial TB, Leprosy and Lung Disease Coordinator in Eastern Province (Kenya). Authorization was also obtained from the persons in charge of the health facilities that were involved in the study.
Moreover, consent was sought from the interviewed patients.

Socio-demographic characteristics of the study participants
Most of the study participants were males (61.4%

Factors associated with the likely completion of medication
The factors significantly associated with importance of completion of medication were the highest level of education (post-secondary) (X 2 =13.643 df =3, p= 0.003) and the patients feeling uneasy during supervision (X 2 =6.659 df =1, p= 0.01). Others included the number of times the patients should take medication (Always) (X 2 =10.818, df =2, p= 0.004) and abuse of substance by the respondents (X 2 =13.933 df =5, p= 0.02) ( Table 1). The study did not measure completion rate.   Table 3 has the summary of the results.

Discussion
The male respondents enrolled in the study were more compared to the female respondents. The study was contrary to a similar study conducted in Kenya on the use of Technology Assisted DOT. The study enrolled an almost similar number of males (49.7%) to females (50.3%) [6]. However, in a study done in Uganda, males were more compared to the females, 57.1% and 42.9% respectively [7]. Gender was not significantly associated (P=0.152) with the patient's knowledge on the importance of completion of tuberculosis medication.
In the study, TB was most prevalent in the adults in the 30-39 years age group. These result agree with the WHO 2009 reported that reported that the majority of persons affected by TB are in their most productive years [7][8][9]. The study participants had attained various levels of education; however, for most participants, primary education was the highest level of education attained followed by secondary education. Similar results were reported in a study done in Uganda, whereby majority of the participants (51%), primary education was the highest level of education followed by secondary school education [7]. The unemployed participants formed the highest category of the respondent in the study (73%), which might be an indication of the poverty level.
The study identified several aspects likely to influence completion of medication among the participants. The results of the study showed that most of the respondents did not like being supervised while taking their medication and more than half of the respondents reported being uncomfortable during supervision. During the in-depth interviews done after a randomized controlled trial in Pakistan, some patients reported that the direct observation of drug taking was unbeneficial and thus they did not comply with the allocated DOT because it inconvenienced them [10]. Moreover, almost 70 percent of the respondents reported that they did not need to be supervised while taking medication. This could be because of the providers' attitude. In the study done in Pakistan, providers' views and cynicism were reported as barriers to DOT [10]. The results of the study showed that the patients were knowledgeable about TB treatment. Over 90% of the participants knew the duration of medication, the importance of treatment completion, and articulated that the medication should always be taken. In the study, 50.7% reported that they liked supervision. However, this was not significantly associated with their knowledge on the importance of completion of tuberculosis treatment (P=0.094).
Feeling uncomfortable during supervision among the participants was significantly associated with their knowledge on the importance of completion of medication (P=0.01). In this study, 23.2% reported that they took medicine solely because of supervision. In a study done in Ethiopia to establish the attitude of the patients towards supervision under the DOT program, the study found out that the majority (60%) of the participants preferred to work with volunteer community health workers as the supervisors during their treatment under the DOT strategy. Only 12.5% of the respondents preferred to be supervised by the family members [14]. However, the study did not seek to determine how they felt about the supervision.
Another study involving Moroccan tuberculosis patients sought to establish the attitudes and knowledge that they had about the treatment of TB. The study divided the patients into either adherent and non-adherent patients. In both groups, 83.8 % of the patients were knowledgeable about the duration of treatment of TB [15]. In our study, all respondents were knowledgeable about the duration of treatment, (8 months for the re-treatment cases and 6 months for first-time treatment). The Moroccan study inquired about the consequence of lack of treatment completion, 13.8% of the respondents had no idea of the consequences and these were mainly the non-adherent one. Knowledge of the consequence of lack of completion of treatment was significantly associated (P=0.01) with adherence to tuberculosis treatment [15]. The findings of the study indicated that 94.3% of the respondents were knowledgeable about the completion of the treatment.

Conclusion
The majority of the respondents in the study were knowledgeable

Competing interests
The authors declare no competing interest.