Assessment of Factors Contributing to TB Treatment Adherence among Patients on TB Treatment in Kano State, Nigeria: A Case Study

Background: The WHO recommended DOTS has been proven to be very effective in the treatment of tuberculosis (TB) patients. However, despite its ef-fectiveness, non-adherence to the treatment regimen remains a major con-cern in TB management. This has great consequences which include persistent infectiousness, higher rates of treatment failure, continued transmission, drug resistance, and untimely death. The aim of this study is to examine the factors and behavioural patterns that contribute to treatment adherence among TB patients in Kano State, Nigeria. Methods: A qualitative study design which included two focus group discussions (FGDs) and four key informant interviews (KIIs) were adopted for this study. In total, 20 participants were interviewed comprising 16 focus group discussion participants (8 patients on treatment and 8 individuals who have been cured) divided into two groups and four key informant interviews with 4 health workers in the selected treatment facilities. Data analysis was done by translating and tran-scribing the responses from the FGDs and KIIs. The transcribed data was analysed using a thematic framework procedure. Results: It was observed that having a good treatment supporter who was effective and very supportive was the most important factor contributing to treatment adherence. Other identified factors that contributed to treatment adherence included: good communication by health personnel, social support from relatives and communities, little or no side effects from drug usage, low cost of transportation to the health facilities, a positive mind set towards drug usage and treatment, support and motivation from health workers, feelings of wellness during treatment, and communication and a cordial relationship do exist with TB patients. Also, TB patients should be properly counselled before the commencement of their treatment regimen to help them maintain a positive mind-set towards treatment. Finally, TB interventions should provide adequate social support for patients.


Background of the Study
Nigeria was listed by the World Health Organisation (WHO) as being among the 30 high burden countries for tuberculosis (TB), and ranking 7 th among the first 10. In Nigeria, the total TB incidence was estimated as 429,000 people (219 per 100,000 population) by WHO in 2018, with about 130,000 deaths occurring from the disease not including deaths from HIV/TB coinfections [1].
Despite its high morbidity and mortality rates, tuberculosis is treatable and curable. WHO has recommended the Directly Observed Treatment Short course (DOTS) for the treatment of tuberculosis-where patients are directly observed while taking their drugs and supported throughout the treatment period. The treatment of tuberculosis for successful outcomes requires at least six months of uninterrupted usage of prescribed first line TB drugs which could be challenging for many patients. The benefits of TB treatment adherence include treatment success and reduction in the risk of transmission. On the other hand, non-adherence has negative consequences such as persistent infectiousness and higher rates of treatment failure, continued transmission, drug resistance, and death [2]. Non-adherence to treatment among TB patients increases the likelihood of developing the drug-resistant strain of the disease, which is more deadly and difficult to treat as higher drug dosages are required.
To combat and reduce the burden of tuberculosis in Nigeria, the National Tuberculosis and Leprosy Control Programme (NTBLCP) was created to reduce TB incidence and increase notification. Several multilateral and bilateral donors such as the United States Agency for International Development (USAID) and Global Fund have also contributed considerably to this cause. Being the most populous state in the country [3], Kano State is among the three states with the highest burden of tuberculosis in the country. Kano state has an estimated TB Prevalence of 45,725 cases (prevalence rate, 330/100,000) and TB case notification target of 6000 cases as of 2018 [4].
As a response to the commitment made by world leaders at 2017 United Nations General Assembly (UNGA) high-level meeting to end TB in 2030, the Kano State Government, in partnership with USAID and other agencies came up with strategies to combat this disease in the State [5]

Objectives of the Study
This study aims to achieve the following: identify the factors contributing to treatment adherence, examine the behavioural patterns that aid treatment adherence and to assess the effect of adherence on treatment outcomes among TB patients in Kano State.

Study Area
The study was carried out in Kano State, which is situated in North West Nige-

Study Population and Sampling Method
This study was conducted among individuals who were beneficiaries of the

Study Design & Data Collection Method
This study adopted a qualitative research design, aimed at understanding the factors that contributed to treatment adherence among the TB patients.

Data Analysis Technique
The researchers discussed and clarified the content of each recording. The notes

Ethical approval was obtained from Kano State Ministry of Health Research Ethics
Committee prior to the conduct of field activities. Participants were not induced or enticed into participating in the research. Participation was voluntary and verbal informed consents were obtained from each of the participants. The participants were not exposed to any harmful or dangerous substance or activity, just strictly interviews. It was ensured that there was no form of discrimination against the participants due to their health status and all participants were adequately protected from risks of infection or re-infection by giving them protective face masks and ensuring interviews were conducted in a spacious and ventilated venue.
All participants' identities were kept confidential; only first names were used during interviews to ensure strict confidentiality and privacy. The confidentiality of information provided by the participants was ensured.

Socio-Demographic Characteristics of Participants
The demographic characteristics of participants of the study included age, gender,     workers accounted for about 20% (4) of the participants.
There were two interview participant categories: 16 (80%) of the participants were interviewed using FGDs, while 4 (20%) participants were Key Informants.
Responses were grouped into three sub-themes: factors contributing to treatment adherence, patient behavioural patterns that engender treatment adherence and effects of treatment adherence on treatment outcomes.

Barriers and Facilitators of Adherence to Treatment
The study participants mentioned factors they thought contributed to treatment adherence. Some of the listed factors included effective and appropriate com- Another respondent, a cured patient, also mentioned that having a good treatment supporter who lives close-by and is very supportive contributes to better treatment adherence. In his own words: "The support I get from my mother has been a key factor in helping me adhere to my drugs, she ensures I use my drug as at when due and cares for me making my wellbeing her concern" (34-year-old Businessman, FGD). Respondents mentioned that distance from health facilities affected treatment adherence and farther distances created transportation cost burden. A respondent who was on treatment mentioned his challenge regarding transportation to health facilities which he stated in his words as follows: "I have experienced difficulty transporting myself to the health facility sometimes no money but most times I have to save enough to cater for my transport to ensure that I don't run out of drugs" (34-year-old Business man, FGD).

Behavioural Patterns that Engender Treatment Adherence
The participants were asked to discuss the behavioural patterns that engender treatment adherence and their responses included: A positive mind set towards drug usage and treatment, support and motivation from health worker, feeling of wellness during treatment and regular consumption of balanced diets.
One of the respondents, a female health worker in one of the treatment facilities stated that a positive mind-set is key to treatment adherence: "For me I believe having a positive mind-set towards drug usage and treatment generally contributes to treatment adherence, most times patients with positive mind-sets tend to adhere better than those without" (Female Health Worker, KI).
Another respondent who was on treatment mentioned that support and care that came from health workers is a motivating factor for treatment ad-

Effects of Treatment Adherence on Treatment Outcome
When asked about the effects of treatment adherence on treatment outcome, all the respondents said that it positively leads to a better treatment outcome. A female health worker (a DOTS Officer) in one of the treatment facilities said: "It is evident that treatment adherence contributes perfectly to treatment outcome, there are so many examples of patients that adhered strictly to their drugs and are now cured in my health facility where I work" (Female Health Worker, KI).
Another respondent, a cured female patient, while also agreeing, said: "For me I know treatment adherence contributes immensely to positive treatment outcome as I am a living testimony" (25-year-old Female Unemployed, FGD).

Discussion
This study provides information on the factors that contribute to tuberculosis treatment adherence as well as behavioural patterns that engender treatment adherence. The study found out that good and effective communication by healthcare personnel, having a competent treatment supporter, social support from relatives and communities, side effects from drugs, low cost of transportation to treatment facilities; positive mind set towards treatment, support and motivation from health worker, feeling of wellness during treatment and the consumption of a balanced diet, all contribute to treatment adherence.
It was observed that effective and sustained communication by health personnel could foster patients' adherence to treatment. TB patients who have a good relationship with health workers tend to adhere to their drug regimen better than those who do not. Health personnel who are friendly and accommodating would keep their patients in treatment better than those who are hostile.
This observation is similar to the findings in a study done in Asmara, Eritrea [11].
The availability of an effective and supportive treatment supporter who is closely related and lives close to the patient is instrumental in improving TB treatment adherence [12]. This study found that the reason for most non-adherence by patients is due to the poor treatment support.  [20] where it was observed that TB patients failed to comply to the TB drug regimen once they started feeling better, this study found out that the feeling of wellness during treatment could serve as a motivating factor for treatment adherence provided that patients knew their treatment duration. When patients feel well during treatment and are equipped with the right information on treatment duration, they tend to stay motivated and focus on getting completely cured.
Consumption of good food and balanced diets has been cited as a key factor that could improve treatment outcomes and support treatment adherence [15].
However, most patients with little or no income could find it challenging to get good food thereby increasing their risk of treatment interruption and should be in place to support rural and poor patients and ensure access to good food as this could improve their retention and treatment outcome. In Peru, the National TB program established a food aid for patients, especially those with low socioeconomic status [15].
This study has assessed factors influencing adherence to tuberculosis treatment in selected health facilities in Kano State. However, this study is not generalizable due to its qualitative nature, but the findings could provide in-depth understanding of the current situation and help policy and programme decision making. Further, nationwide, preferably quantitative, studies should be conducted to broaden the current understanding of the factors associated with TB treatment adherence in Nigeria.

Conclusion
This study showed that factors such as; good and effective communication by health personnel, availability of competent treatment supporters, social support from relatives and communities, minimal side effects from TB drug use and low transportation cost to health facilities contributed to treatment adherence., It was also found that behavioural patterns such as; a positive mind set towards treatment, support and motivation from health workers, feeling of wellness during treatment, complete and balanced diet all engender treatment adherence which impacts positively on treatment outcomes. For better treatment adherence, an experienced and effective treatment supporter should be selected by TB patients, health workers should ensure effective communication and maintain friendly relationships with TB patients. TB patients should be properly counselled before being commenced on treatment to help them maintain a positive mind-set towards treatment while also supporting them socially and financially especially in the provision of good food and treatment support.