INT J TUBERC LUNG DIS 12(10):11601165

2008 The Union

Factors contributing to treatment success among tuberculosis

patients: a prospective cohort study in Bangkok

K. Okanurak,* D. Kitayaporn* P. Akarasewi

* Department of Social and Environmental Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok,
Clinical Research Centre, Bumrungrad International Hospital, Bangkok, Bureau of HIV/AIDS, TB and STIs,

Department of Disease Control, Ministry of Public Health, Bangkok, Thailand

SUMMARY

SETTING: Chest Clinic, Ministry of Public Health and
health care centres, Bangkok Metropolitan Administra-
tion.
O B J E C T I V E : To determine patient factors predicting
successful tuberculosis (TB) treatment.
D E S I G N : A prospective cohort was conducted during
May 2004 to November 2005. Newly diagnosed TB pa-
tients aged 15 years were recruited after giving in-
formed consent. Three sets of questionnaires were used
to collect data from the patients three times. Data were
also gathered from treatment cards.
R E S U LT S : Of 1241 patients, 81.1% were successfully
treated. Bivariate analysis indicated that patients sex,
education, occupation, level of knowledge about TB and
adverse effects were associated with treatment success.
Unconditional logistic regression analysis showed that
females had a higher success rate than males (OR = 1.9,
95%CI 1.22.9). Patients with regular incomes had twice
the likelihood of success of the unemployed (OR = 2.0,
95%CI 1.13.5). Patients with high knowledge levels
were more likely to complete treatment (OR = 2.0,
95%CI 1.23.4), while those with adverse effects were
less likely to adhere (OR = 0.6, 95%CI 0.40.9).
C O N C L U S I O N : The current low treatment success rate
may be partly due to inadequate knowledge about TB
among patients. Improvements in health education and
early detection and management of adverse effects should
be prioritised by the National Tuberculosis Programme.
K E Y W O R D S : treatment success; TB patient; prospective
cohort

TUBERCULOSIS (TB) is curable and preventable;
nevertheless, one third of the worlds population is
infected. There were an estimated 8.8 million new TB
cases and 1.6 million deaths due to TB in 2004.1 Resis-
tance to single drugs has been reported in every coun-
try, and resistance to all of the major anti-tuberculosis
drugs has now emerged.2 The overall treatment success
rate worldwide was 84% in 2004; 10% of all new pa-
tients treated under the DOTS strategy were reported
as defaulters, transfers or as not being evaluated.1
Adherence to TB treatment is particularly impor-
tant for TB control programmes, as non-adherence
can contribute to the ongoing spread of disease and
the emergence of drug-resistant TB in the commu-
nity.3 TB treatment requires taking several drugs to-
gether for at least 68 months; adverse effects do occur
and patients will usually feel better after taking their
medications for a few weeks.4 Some patients stop treat-
ment because they believe their TB has been cured af-
ter the symptoms have abated.5,6 In addition to the
nature of treatment, barriers to TB treatment adher-
ence include the health care system, and provider and
patient factors.3
In relation to the health care system, lack of regular
drug supplies,7 long waiting hours8 and inconvenient
clinic opening times9 have been identified as factors
associated with non-adherence. Physicians ability to
deal with adverse effects,9 prescribing practices10,11
and providers attitudes12 were predictors for provider-
related patient non-adherence.
A number of studies focusing on TB patient factors
have been conducted on the determinants of non-
adherence to treatment; however, the results were not
consistent. Some studies reported that the patients
occupation,13 sex,1316 employment status14,15,17 and
education13 did not affect non-adherence, while oth-
ers found them to be significant predictors of non-
adherence.12,1820 Knowledge about TB and its treat-
ment influences patient decision making, but its effect
on patient adherence is unclear. Different studies
have shown different impacts for knowledge, rang-
ing from no relationship13,15 to a positive link.12,2123
Several studies found that social stigma affected non-
adherence,12,24,25 while a study in Saudi Arabia re-
ported that stigma did not affect adherence.5 Other ex-
amples of variables related to patient non-adherence

Correspondence to: Kamolnetr Okanurak, Department of Social and Environmental Medicine, Faculty of Tropical Medi-
cine, Mahidol University, 420/6 Ratchawithi Road, Ratchadewee, Bangkok 10400, Thailand. Tel: (+66) 2354 9100. Fax:
(+66) 2354 9166. e-mail: tmkok@mahidol.ac.th
Article submitted 5 November 2007. Final version accepted 30 May 2008.
[A version in French of this article is available from the Editorial Office in Paris and from the Union website www.iuatld.org]

have included adverse effects,9,21,26 belief that the dis-
ease was cured9 and relief from symptoms.6
TB continues to be a major public health problem
in Thailand, which ranks 17th among 22 high-burden
TB countries by estimated number of cases. In 2005
an estimated 91 000 new cases were reported, giv-
ing an incidence of 142 per 100 000 population. The
DOTS strategy was initiated in 1996 and reached
100% national coverage in 2002.27 However, in 2004,
the treatment success rate was 74% (compared to
high-burden country and global averages of 84% and
86%,1 respectively). To achieve the global treatment
success target of 85%, it would be helpful to deter-
mine factors predictive of success. The present study
therefore aimed to investigate factors predictive of suc-
cessful treatment for TB patients.
MATERIALS AND METHODS
Details of the study design, setting and subject recruit-
ment have been published elsewhere.28
Data collection
Three sets of structured questionnaires were developed
based on information gathered from in-depth inter-
views of TB patients who were newly diagnosed, were
being treated in the intensive or continuation phases,
or who had completed or defaulted from treatment.
The questionnaires were pre-tested and modified be-
fore being used in interviews of registered patients.
The internal reliability of knowledge part (Kuder-
Richardson) and attitude part (Cronbachs alpha) were
respectively 0.81 and 0.75.
Before starting the interviews, the patients were in-
formed about the purpose of the interview and all pro-
vided written informed consent. Each patient was in-
terviewed three times: at enrolment in the study, at the
end of the intensive treatment phase and at the end of
treatment. The first interview mainly covered the pa-
tients socio-demographic information and their reac-
tion when informed of the diagnosis. The second in-
terview included adverse effects of anti-tuberculosis
drugs, and knowledge and attitudes regarding TB and
its treatment. The last interview covered areas such as
changes in everyday life during treatment, changes in
drug administration methods, and reasons for com-
pleting or defaulting from treatment.* The treatment
outcome was obtained from the standard treatment
card of each patient. Data were recorded without
names, ensuring confidentiality.
Patients knowledge of TB and its treatment were
assessed using 15 questions. One point was awarded
for each correct answer; the scores ranged from 0 to
32. The assessment of patient attitudes consisted of
* This paper does not cover results of the third interview because
they were not directly related to the papers objective; however, some
reasons for defaulting from treatment are used in the discussion.
Factors of treatment success 1161
17 statements. For positive statements, answers were
graded as yes = 3, not sure = 2, and no = 1. For nega-
tive statements, answers were graded as yes = 1, not
sure = 2, and no = 3. The possible range of scores
was 1751.
Ethical considerations
The study was approved by the Committee on Hu-
man Rights Related to Human Experimentation, Ma-
hidol University, Bangkok and the Ministry of Public
Health (MOPH) Ethics Review Committee for Re-
search into Human Subjects, Bangkok.
Data management and analysis
All data were recorded without patient names, thus
ensuring confidentiality. The data were double-entered
into Epi Info 6.04d software (Centers for Disease Con-
trol and Prevention, Atlanta, GA, USA), then verified
and checked for errors.
The primary outcome of this study was treatment
success. Patients were defined as successfully treated
if they had been cured or had completed treatment.
A patient was considered cured if initially smear-
positive and smear results were negative in the last
month of treatment and on at least one previous oc-
casion. A patient was defined as completed treatment
if the patient had completed treatment but did not
meet the criteria for cure or failure. This definition
applied to patients with smear-positive and smear-
negative pulmonary TB and extra-pulmonary TB.
Death was recorded for patients who died from any
cause during treatment. Treatment failure was de-
fined as a patient who was initially smear-positive and
remained smear-positive at month 5 or later during
treatment. A patient was considered a defaulter if treat-
ment was interrupted for 2 or more consecutive
months. A patient was considered transferred out if
transferred to another reporting centre, with no known
treatment outcome.1
2 was used in bivariate statistical analysis to assess
the relationship between risk factors and treatment
success rates. Variables for the multivariable step-wise
unconditional logistic regression model were included
if they showed a bivariate association with treatment
success, with P < 0.1 indicating significance. Stata SE
for Windows version 9.2 (StataCorp Inc., College Sta-
tion, TX, USA) was used in the statistical analysis.
RESULTS
A total of 1241 new registered TB patients were en-
rolled into this cohort study: 931 (75%) from health
care centres under the Department of Health, Bang-
kok Metropolitan Administration (BMA Health Cen-
tres) and the remaining 310 (25%) from the Bangkok
Chest Clinic, Tuberculosis Cluster, Ministry of Public
Health (MOPH Clinic) (Table 1).
The number of males was about twice that of
1162 The International Journal of Tuberculosis and Lung Disease

Table 1 Characteristics of tuberculosis patients registered Table 2 Treatment outcomes

for treatment
Treatment outcome n (%)
Characteristics n (%)
Successful 1007 (81.1)
Health service Cured 550 (44.3)
BMA health centre 931 (75.0) Completed 457 (36.8)
MOPH clinic 310 (25.0) Not successful 234 (18.9)
Sex Died 37 (3.0)
Male 819 (66.6) Failed 28 (2.3)
Female 422 (33.4) Defaulted 71 (5.7)
Transferred 98 (7.9)
Age, years
1520 60 (4.8) Total 1241 (100)
2130 355 (28.6)
3140 340 (27.4)
4150 236 (19.0)
5160 150 (12.1)
>60 100 (8.1) The mean score (SD) for patient attitudes was
Education 40.4 3.54 (range 2949). Using mean 0.5 SD as
Illiterate 95 (7.7) cut-points, 33.4% of patients had positive, 25.8%
Primary school 673 (54.2) negative and 40.8% neutral attitudes towards TB and
Secondary school 344 (27.7)
Higher 129 (10.4) its treatment (Table 1). About 70% of patients re-
Occupation ported no adverse effects from treatment (Table 1).
Unemployed 414 (33.4) The treatment success rate was 81.1%, with default
Daily wage 317 (25.5) and transfer-out rates of respectively 5.7 and 7.9%
Monthly wage 260 (21.0)
Other 250 (20.1) (Table 2). Bivariate analysis showed an association
Income, baht (n = 769) between treatment success and sex, education, occu-
Range 25050 000 pation, level of knowledge and adverse effects (P
Mean 7554.85 0.05 for each variable, Table 3).
< mean 67.6%
> mean 32.4% Unconditional logistic regression analysis was used
Knowledge level to determine the association between treatment suc-
Low 307 (27.3) cess and selected predictive variables (Table 4). Pa-
Moderate 502 (44.6) tients sex, occupation, level of knowledge and ad-
High 317 (28.1)
verse effects were associated with treatment success
Attitude level
Negative 290 (25.8) rate. Female patients had a higher treatment success
Neutral 460 (40.8) rate than males (odds ratio [OR] 1.9, 95% confidence
Positive 374 (33.4) interval [CI] 1.22.9). Compared with the unemployed,
Drug adverse effects both patients who earned incomes from regular
No 792 (70.5)
Yes 331 (29.5) monthly jobs and those who had some other kinds of
BMA = Bangkok Metropolitan Administration; MOPH = Ministry of Public
Health.
Table 3 Factors associated with treatment success

Treatment outcome
females; 56% were between 21 and 40 years of age Successful Not successful
and 8.1% were aged >60 years. Slightly more than Patient factors n (%) n (%) P value
half (54.2%) of the patients had completed primary Sex 0.05
education, 27.7% had finished secondary education Male 652 (79.6) 167 (20.4)
and 7.7% were reported as illiterate. One third (33.4%) Female 355 (84.1) 67 (15.9)
were currently unemployed, 25.5% were daily wage Education 0.045
Illiterate 69 (72.6) 26 (27.4)
workers, 21% earned monthly incomes from regular Primary school 540 (80.2) 133 (19.8)
jobs and 20.1% had other kinds of work. The range Secondary school 287 (83.4) 57 (16.6)
of incomes was 25050 000 baht/month (US$6.35 Higher 111 (86.0) 18 (14.0)
1270.97) with a mean, for those who were working, Occupation 0.000
Unemployed 307 (74.2) 107 (25.8)
of 7554.85 baht/month (US$192.04). Using the mean Daily wage 259 (81.7) 58 (18.3)
income as the cut-off point, 67.6% of working pa- Monthly wage 221 (85.0) 39 (15.0)
tients had less-than-average incomes and 32.4% had Other 220 (88.0) 30 (12.0)
above-average incomes (Table 1). Level of knowledge 0.012
Low 259 (84.4) 48 (15.6)
Patients knowledge scores ranged from 1 to 30 Moderate 451 (89.8) 51 (10.2)
(mean 14.2, standard deviation [SD] 4.47). Using High 290 (91.5) 27 (8.5)
mean 0.5 SD as cut-off points, 44.6% of patients Adverse effects 0.02
had moderate, 28.1% high and 27.3% low knowl- No 715 (90.3) 77 (9.7)
Yes 283 (85.5) 48 (14.5)
edge of TB and its treatment (Table 1).
 Factors of treatment success 1163

Table 4 Factors predictive of successful treatment ment success. Patients with better occupations had a
Characteristics OR 95%CI P value two-fold better rate of treatment success than those
who were unemployed or worked for daily wages. The
Sex
Male 1.0* monthly wage workers with stable incomes could af-
Female 1.9 1.22.9 0.01 ford the regular costs of transportation to the treat-
Occupation ment centre, whereas those who were unemployed or
Unemployed 1.0* worked for daily wages might not. These two latter
Daily wage 1.4 0.92.2 0.16
Monthly wage 2.0 1.13.5 0.01 groups may require additional assistance to access
Other 2.0 1.13.5 0.02 treatment besides free diagnosis and treatment at the
Level of knowledge clinic.
Low 1.0* Patients knowledge level of TB and its treatment
Moderate 1.7 1.12.6 0.02
High 2.0 1.23.4 0.01 contributed to treatment success. Adequate knowl-
Adverse effects edge is needed to change peoples attitudes towards
No 1.0* their behaviours; these attitudes can then influence
Yes 0.6 0.40.9 0.01 the intention to perform certain behaviours, eventu-
Goodness of t statistics of the model, P = 0.14. ally leading to practice of the desired behaviours.30 It
* Referent. may thus be inferred that adequate knowledge of TB
OR = odds ratio; CI = condence interval.
and the impact of non-adherence to treatment are ba-
sic requirements for developing positive attitudes and
income had twice the chance of successful treatment good intentions, and consequently completing treat-
(OR 2.0, 95%CI 1.13.5). However, treatment suc- ment. The present study found health education at the
cess among patients working for daily wages was not clinic to be limited. The patients were told to take
significantly different from that in the unemployed. their medicine continuously for 6 months, but no rea-
Patients with moderate or high levels of knowledge son was given nor any explanation of the consequences
about TB and its treatment were about twice as suc- of non-adherence. This kind of information is critical
cessful as those with low levels of knowledge (OR to encouraging patients to complete treatment, as most
1.7, 95%CI 1.12.6 vs. OR 2.0, 95%CI 1.13.5). Pa- symptoms disappear after the first few weeks of treat-
tients with adverse effects had about 60% likelihood ment. In addition, the education delivery process
of success compared with those who did not (OR 0.6, should be effective. It was observed that the education
95%CI 0.40.9). provided mostly comprised a brief talk about TB and
its treatment during the first visit. To achieve a higher
rate of successful treatment, both the educational ma-
DISCUSSION
terial and the education delivery process should be
This cohort study was conducted in Bangkok Metro- improved.
politan Area, and covered 63 BMA Health Centres The adverse effects of anti-tuberculosis drugs also
and the MOPH Bangkok Chest Clinic. Male patients contribute to the success or failure of treatment. Cur-
were predominant. Most patients had completed pri- rently prescribed medications have fewer adverse ef-
mary school education, which was compulsory, but fects, but these still occur in some patients: some stop
some were still illiterate. One third of patients were taking their medication when they encounter adverse
unemployed. Moreover, almost 70% of working pa- effects such as nausea. All new patients should be ad-
tients had incomes lower than the average income of vised about potential adverse effects and the possibil-
the group, which in turn was less than the average in- ity of changing medication if they are severe. The Na-
come for Bangkok (8888.8 Baht/month).29 This sug- tional Tuberculosis Programme (NTP) should also
gests that the socio-economically disadvantaged were include early detection and management of adverse
more vulnerable to TB. effects in the implementation plan.
The treatment success rate was 81.1%, which was It is of note that the strength of each variable asso-
below the World Health Organization (WHO) target ciation is not that high (2.0) and that the lower lim-
of 85%, but higher than the national rate of 74% its of the CIs, despite being in the significant region,
(2004). Success rates were associated with sex, educa- are close to 1. This could occur because of other un-
tion, occupation, level of knowledge about TB and its recognised confounding variables and possibly the
treatment, and adverse effects. Of these five variables, small sample size in each stratum.
sex, occupation, level of knowledge and adverse ef- This study was limited by patient drop-out due to
fects were predictors of treatment success. The find- transfers out, death and some defaulting. For such
ing that the treatment success rate was higher for fe- groups, second and third interviews were not possi-
males than males might reflect the health behaviour of ble. These missing data (118/1241, 9.5%) should not,
females, who may have paid more attention to their however, substantially affect the estimates of the
health than males. association.
Occupation was another factor that affected treat- In conclusion, this study demonstrated that patients
1164 The International Journal of Tuberculosis and Lung Disease
sex, occupation, knowledge about TB and its treat-
ment, and adverse effects could be predictive of suc-
cessful treatment, at least in the Bangkok Metropoli-
tan Area, if not throughout Thailand. If a TB patient
presenting for treatment were female, had a stable oc-
cupation and good knowledge about TB and its treat-
ment, there was a high likelihood that she would ad-
here to the treatment regimen. Although the first two
factorssex and occupationare beyond the pur-
view of health care providers, the providers can use
such information in designing educational messages
according to the patients sex and occupation. To
achieve the target of successful treatment, both the
educational materials and delivery process in the edu-
cational component should be improved. Appropri-
ate materials and an effective delivery process should
be used to attract the attention of patients. With more
effective education, patients would perceive the bene-
fits of treatment more clearly, resulting in better ad-
herence to the full course of treatment. Moreover,
early detection and management of adverse effects
should be prioritised by the NTP to reach the WHO
targets for treatment success.
Acknowledgements
The authors wish to thank all the patients who volunteered for this
study. This investigation received financial support from the United
Nations Childrens Fund/United Nations Development Programme/
World Bank/WHO Special Programme for Research and Training
in Tropical Diseases (TDR).
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C O N T E X T E : Clinique thoracique, Ministre de la Sant
publique et Centre de soins de sant, Administration
mtropolitaine de Bangkok.
O B J E C T I F : Dterminer les facteurs-patient permettant
de prdire le succs du traitement de la tuberculose (TB).
S C H M A : On a suivi une cohorte de manire prospec-
tive entre mai 2004 et novembre 2005. Les patients TB
rcemment diagnostiqus, gs de 15 ans, ont t re-
cruts aprs consentement clair. On a utilis trois
sries de questionnaires pour colliger trois reprises les
donnes provenant des patients. Des donnes ont t
galement rassembles partir des cartes de traitement.
R S U LTAT S : Le traitement a t couronn de succs
chez 81,1% de 1241 patients. Lanalyse bivarie a in-
diqu que le succs du traitement est en association avec
le sexe du patient, son degr dducation, son type doccu-
pation, son niveau de connaissance en matire de TB ainsi
M A R C O D E R E F E R E N C I A : La Consulta de neumologa
del Ministerio de salud pblica y los Centros de salud de
la Administracin metropolitana de Bangkok.
O B J E T I V O : Determinar los factores dependientes del
paciente que predicen el xito del tratamiento anti-
tuberculoso.
M T O D O : Se llev a cabo un estudio prospectivo de co-
hortes entre mayo de 2004 y noviembre de 2005. Se in-
cluyeron en el estudio los pacientes de 15 aos con di-
agnstico reciente de tuberculosis (TB), una vez recibido
su consentimiento informado. Se utilizaron tres series de
cuestionarios a fin de recoger datos de los pacientes en
tres oportunidades. Tambin se recogieron datos a partir
de las tarjetas de tratamiento.
R E S U LTA D O S : De los 1241 pacientes, el 81,1% recibi
un tratamiento exitoso. En el anlisis bifactorial se en-
contr que el sexo, la educacin, la ocupacin, el nivel
de conocimiento sobre la TB y las reacciones adversas
Factors of treatment success 1165
30 Fishbein M, Ajzen I. Belief, attitude, intention and behavior: an
introduction to theory and research. Reading, MA, USA:
Addison-Wesley, 1975.
RSUM
quavec les effets indsirables. Une analyse de rgression
logistique inconditionnelle a montr que le taux de suc-
cs est plus lev chez les femmes que chez les hommes
(OR 1,9 ; IC95% 1,22,9). La probabilit de succs est
double chez les patients dont les revenus sont rguliers
par rapport aux sans emploi (OR 2,0 ; IC95% 1,13,5).
Les patients dont les niveaux de connaissance sont plus
levs sont plus susceptibles dachever leur traitement
(OR 2,0 ; IC95% 1,23,4), alors que ceux souffrant
deffets indsirables ont une adhsion thrapeutique moins
probable (OR 0,6 ; IC95% 0,40,9).
C O N C L U S I O N : Les faibles taux actuels de succs du trai-
tement peuvent tre dus en partie aux connaissances inad-
quates des patients. Le Programme National de la TB
devrait se focaliser sur une amlioration de lducation en
matire de sant et une dtection et une prise en charge
prcoces des effets indsirables.
RESUMEN
se asociaron con el xito teraputico. El anlisis de re-
gresin logstica incondicional puso en evidencia que las
mujeres presentaron una tasa de xito ms alta que los
hombres (OR 1,9 ; IC95% 1,22,9). Los pacientes con
un ingreso estable presentaron una probabilidad de xito
teraputico dos veces superior a los desempleados (OR
2,0 ; IC95% 1,13,5). Los pacientes con un mayor grado
de conocimientos presentaron ms probabilidad de com-
pletar el tratamiento (OR 2,0 ; IC95% 1,23,4) y aquellos
con reacciones adversas, menor probabilidad de cumplir
con el tratamiento (OR 0,6 ; IC95% 0,40,9).
C O N C L U S I N : La baja tasa actual de xito del trata-
miento antituberculoso se puede deber en parte a los es-
casos conocimientos de los pacientes. El Programa nacio-
nal contra la TB debe dirigir sus esfuerzos al mejoramiento
de la educacin en salud, la deteccin temprana y al trata-
miento de los efectos adversos.