Rennie, Timothy William; (2007) Adherence to medical management in tuberculosis populations in northeast London: An exploration of medical and behavioural factors. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Prevention and treatment of tuberculosis (TB) by medical means has existed since the 1950s and the World Bank considers the World Health Organisation "DOTS" strategy to be one of the most cost-effective of any health intervention. However, rates of TB have been increasing in the UK since the mid-1980s with the greatest increase observed in London amongst patients born outside the UK. In addition, antibacterial resistance is prevalent and continues to increase. This suggests a failure of the biomedical model with a lack of focus on the behavioural element of patient management. This thesis presents two research studies that addressed the issue of non-adherence to medical management of TB in order to better inform any intervention to improve adherence in this disease group or further research with this intention. The first study was a retrospective analysis of seven years latent TB patient data. In particular, this compared the two most commonly prescribed regimens - 6-month isoniazid and 3-month rifampicin/isoniazid combination - and whether a choice of regimen was offered, after 1st April 2000. As there can be no specific clinical outcome, the outcome measure used was completion of medication. Results demonstrated that patients prescribed the combination regimen, those offered choice of regimen, and patient age were related to treatment completion such that older patients, those not offered choice and those prescribed isoniazid regimen were more likely not to complete treatment (fail). Adverse drug reactions were not related to treatment outcome. Kaplan-Meier survival analysis suggested that the highest probability of treatment failure was at the beginning of treatment and that, after 13 weeks of treatment, the probability of failure in patients prescribed isoniazid was significantly higher. The second study was an exploratory study of TB patient perceptions of their illness and medication and whether these were related to adherence, measured as attendance to scheduled clinics. A questionnaire incorporating the Revised Illness Perceptions Questionnaire (IPQ-R), the Perceived Utility of Medicine (PUM), a self-reported measure of adherence to medication, and various sociodemographic indicators was administered to consenting patients attending three TB clinics in Northeast London over a period of approximately 18 months. Due to the high proportion of immigrant patients in this TB population, the questionnaire was translated into the three most common languages in participating clinics. To assure the accuracy of translation, a four-stage protocol was developed to validate the translation a priori and post hoc. Multiple regression analysis of results suggested that patients speaking English as their first language, those with negative perceptions of their illness and, to a lesser extent, male patients and patients reporting non-adherence to medication, were less likely to attend scheduled clinic. These studies identified, in two distinct TB patient populations, a number of modifiable factors that could be used to address the issue of non-adherence to medical management. The first study highlighted the importance that patients attribute to duration of treatment such that if patients were offered shorter regimens, treatment outcomes would likely be more positive. In the second study, two factors that represented most variance in adherence imply a strong social and psychological link with adherence, over and above any medical or demographic variables, that may inform future interventions.

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