Chapter Two
4.5 Perception of AdherencelNon-adherence in the Development of MDR-TB
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Another patient who concurred with the above patient's response, reported that he defaulted treatment exactly because of his feelings of depression and loss of hope in ever recovering from his illness. It is· therefore vital that patients benefit from a systematic counselling programme as an integral part of their treatment regimen.
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Patient (male): When I arrived here I was told that MDR-TB is caused by defaulting treatment.
Patient (female): I had been taking treatment for TB and never defaulted my treatment even once. I got hurt when it was alleged that I got MDR-TB through defaulting treatment.
One male participant reported that he felt that he was blamed by a health care professional for mismanaging his treatment when in fact he was unaware of the duration of the treatment protocol.
Patient (male): I was initially told that I had TB and was subsequently put on treatment.
When my condition showed no sign of improvement, I went to see a physician who scolded me and said I did not allow my treatment enough time to take effect. He nonetheless referred me to the hospital.
The above extract demonstrates clearly that health care professionals have at times assumed that patients are aware of treatment protocols and may have neglected to adequately inform patients of the process or duration of treatment. This extract also throws light on the process by which the already low levels of self-respect/self efficacy patients have in managing their own health status is reinforced by health care professionals, who often tend to view patients as being helpless and irresponsible.
By contrast, one female participant who had worked for the TB centre reported that she understood the implications of defaulting treatment, although she personally reported not defaulting treatment. The paradox here lies in the fact that health messages and indeed her own perceptions may be falsified by her own development of the disease without having defaulted treatment. This again underscores the need for a counselling programme to ensure a common understanding of the entire treatment protocol between patients and health care professionals.
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4.6 Possible Delay in Diagnosis of Primary Conditions
One male participant reported that a physician initially treated him for a fever. After being referred to the chest clinic he was told that he was healthy. After the patient allegedly insisted that he be further examined, a diagnosis of TB was returned. After being treated for nine months, his condition persisted and he was then diagnosed as suffering from MDR-TB. This patient accordingly ascribed the development of his MDR- TB to a failure by health care professionals to initially identify their condition and provide appropriate management immediately. The majority of male participants supported this view.
One male participant reported that he felt that health care professionals failed to diagnose MDR-TB early on and treated him for TB instead, which resulted in the disease becoming stronger. This was felt to affect the prognosis of his condition, which impacted significantly on his quality of life. Other conditions reported by patient's that were treated prior to the diagnosis of TB was fever, influenza and in some cases pneumonia. Most of the participants felt that X-RAYS provided the most conclusive results, especially for patients being assessed for TB, and that this was not done on them.
Similarly, the majority of female pm1icipants reported initially being treated at health care facilities for influenza, severe coughs and colds. These participants strongly believed that their health status might have been compromised due to the delay in diagnosis. Of concern is the lack of early detection facilities in aiding health care services to make appropriate diagnosis and referrals, so as to prevent patients who are possibly suffering from TB/MDR-TB, from experiencing treatment delays.
Patient (female):
I initially felt I had flu and sought treatment at a local clinic where I
was given cough mixture and tablets. I failed to show any signs of
improvement. Subsequently I was diagnosed as suffering from TB and
was put on TB treatment for four months. When my condition did not
improve I was then transferred to KGY ... my new physician
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diaonosed me as suffering from MOR-TB.o '-
Patient (female): Professionals lack of knowledge of MOR-TB and their inability to detect the disease early in its onset is a problem. Nurses also gave me different instructions for my treatment.
Most participants (both male and female) described incidents of a similar nature, where the diagnosis of TB was made only after an extended period of time/clinic visits/ other therapeutic interventions. Understandably, not every cough or fever is indicative of TB. It is therefore expected that where clinical assessment does not suggest the immediate need for more objective investigations, TB might not be immediately diagnosed. This is especially understandable in view of our scarce health resources and the sheer pressure exerted on understaffed and ill-equipped primary health care centres. Notwithstanding this, the cumulative effect of these factors have resulted in patient's being mismanaged and treated for 'common illnesses', when in fact they may have been suffering from TB/M OR-TB at the outset. This further erodes participant's trust in their treatment efficacy and undermines their relationship with and faith in health care professionals and health services.
The amount of time lost, which contributed to the delay in diagnosis could explain or possibly contribute to the lack of these participants faith in treatment. Early detection and diagnosis of MOR-TB, as well as adequate explanations regarding treatment protocols, would circumvent treatment delay and improve patient adherence and therapeutic efficacy. One male patient reported the following:
Patient (male): Ubudedengu babezempilo (attributing blame to health care professionals for mismanaging treatment), especially in terms of treatment as a source of the disease. If treatment were initially geared towards MOR-TB, then I would have recovered speedily.
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