A study on performance evaluation, roles and challenges faced by the DOTS providers in treatment adherence of TB patients in Tumkur city an untouched area

Introduction

The necessity of directly observed treatment (DOT) for tuberculosis control was first demonstrated in India.1 DOT is now recommended as the standard of care in treatment of tuberculosis worldwide.2, 3 By ensuring that patients take the right drugs, at the right intervals and in the right dosages, DOT reduces the chances of relapse or failure and prevents multi-drug resistant tuberculosis.4, 5, 6

Since 1962 various forms of modalities were structured and implemented but disease itself poses new challenges and modified threats to public health of India.

Latest version of challenges in TB is in the form of MDR and XDR.

Many literature claims MDR and XDR are manmade TB, mainly because of failure to adhere to the treatment of primary TB. In order to prevent the newer threat, important strategy used in RNTCP in India is DOTS, where designated worker/ volunteers called DOTS provider plays anchoring role in adhering to TB treatment.

With this background the investigators would like to conduct research with the objectives of evaluating the performance of DOTS provider, assessing the role of DOTS provider in treatment adherence and the Challenges faced by the DOTS Provider in delivering DOTS.

Materials and Methods

After taking Informed consent a Cross-sectional study was done using semi structured questioner which contains Socio-demographic characteristics of the DOTS provider and the questions to evaluate the performance of DOTS provider, his role in treatment adherence and also the challenges faced by him/her. DOTS providers are traced by information obtained from DTC. Data will be collected using semi structured pretested questioner by interview technique.

Data was entered and analysed using SPPSS version 16.0.

Objectives

Results

Most of the Dots Provider were Asha Worker, out of which 60% of them became DOTS providers in order to provide social service.

Around 99% of DOTS providers have received training regarding TB and DOTS. Out of which 59.9% of them felt that the training they received was adequate and rest felt that it was inadequate. 81.2% of them were able to answer all queries of TB patients and 11.9% of them were able to answer some of the queries and 2% were not able to answer the queries at all.

95% of them believed that taking DOTS will completely cure TB, 70% believed that the reason of failure was due to incomplete treatment and 15% believed that the failure was due to incomplete treatment and failure of preventive measures about 7% percent believed the failure was due to failure of preventive measure and others believed that the disease is incurable and due to lack of knowledge.

98% of them trace the patients when they don’t come to take DOTS. 91.1% of them had no history of TB in their families and 7.9% of them had a history of TB in their family. Around 53.5% of DOTS provider handled the drug reaction, around 28% of DOTS provider gave the responsibilities to their spouses when out of station, around 77.2% of them think that honorarium provided for the work is satisfactory. About 95% of them were aware of protecting themselves from infection. Around 80.2% of them had no MDR TB patients under them, about 10.9% had one MDR TB patient, around 38.6% of them were cured and declared sputum negative. Most of them 94.1% of them had no defaulters and 4% of them had one defaulter under them. 11.9% of them had one relapse, around 93.1% of them had no failures, 5% of them had one failure and 1% of them had 2 failures, around 95% of them used counseling as an aid to motivate patients.

Discussion

High treatment success rates can be achieved by identifying DOT providers, who are accessible and acceptable to patients.

In our study around 38.6% of them were cured and declared sputum negative. Most of them 94.1% of them had no defaulters and 4% of them had one defaulter under them. 11.9% of them had one relapse, around 93.1% of them had no failures, 5% of them had one failure.

A Study done in Africa, volunteers and community health workers successfully delivered community-based DOT and were able to maintain higher treatment completion rates than the health worker in a clinic.7

Decentralized approach using a network of community-based DOT providers can take DOTs delivery closer to patients’ homes, training and supervision of community-based DOT providers may not be optimal in the RNTCP as currently implemented.

Medical officers in charge of PHCs monitor activities of the governmental staff through weekly review meetings. However, periodic supervision of Anganwadi workers and community volunteers is infrequent. To increase the accountability of community-based DOT providers, it is necessary to develop and test mechanisms for supervising these providers.

Poor treatment outcomes will be no more common among patients who reports drug related problems than among those who do not. Patients treated by Anganwadi workers and community volunteers, however, were more likely to report drug related problems than those receiving treatment from government providers.

Government DOT providers are skilled in tackling patients’ drug related complaints, whereas Anganwadi workers and community volunteers have minimal training in health related issues. Therefore, the training of Anganwadi workers and community volunteers should include a strong component, on how to counsel patients who have drug related problems. Anganwadi workers and community volunteers may also be trained to dispense minor drugs such as antacids, analgesics and antihistamines.

Volunteer health workers have been successfully trained to dispense similar drugs in primary health care programmes in India and elsewhere.8, 9

Appropriate utilization of DOTS provider, Educating them regarding the disease and drug reaction and motivating them to provide service helps to improve treatment success rate and success of TB programme.

Conclusion

All though most of DOTS provider received training, still they found difficulties in managing the patient, appropriate strategies to be developed to handle the difficulties in delivering the programme need to be framed.

Recommendation

The importance of participating in directly observed treatment should be effectively communicated

to patients as well as DOT providers, especially during Pandemic period, as patients and DOTS Providers will be anxious and scared to visit the hospital.