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Operational Research Study for “Evaluation of the Effectiveness of the National DOTS Programme and to propose alternate models to improve provision of DOTS in various settings”

K.C.S. Dalpatadu Chandra Sarukkali Chamara Anuranga Kasun Chandradasa Chitramali Rodrigo

Sameera Ruwanpriya

Institute for Health Policy, Colombo, Sri Lanka

June 2010

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Acknowledgements This review was carried out by a research team based at the Institute for Health Policy, Colombo, Sri Lanka, and led by Dr. K.C.S. Dalpatadu. Funding for this study was provided from the GFATM Round six TB grant through Sarvodya, Principle Recipient 2. The views in this report are those of the authors, and should not be attributed to the Institute for Health Policy (IHP). The research team wishes to acknowledge the support and input of many colleagues for this work, and in particular officials of Ministry of Healthcare and Nutrition, National Programme for Tuberculosis Control and Chest Diseases and the Provincial Health Authorities. We thank the Secretary of Ministry of Healthcare and Nutrition Dr Athula Kahandaliyanage and The Director General of Health Services Dr Ajith Mendis for the approval and support given for conducting this study in Sri Lanka. Our thanks are also due to Dr P. Mahipala (Deputy Director General, Public Health Services (1) and to Dr Sunil de Alwis D/NPTCCD and his staff in particular, for the valuable insights given to us which immensely helped us in completion of the study, as it focused on the performance of the national DOTS programme. We acknowledge the assistance rendered to us and to our survey teams by the PDHSs and RDHSs of the six provinces and nine districts where the field surveys were carried out which enabled us to conduct the field surveys without hindrance within the time frame we had planned. We thank all the DTCOs from the selected districts for their supervisory roles and their Public Health Inspectors, who helped us to collect accurate data for this study through the field surveys. We thank Dr Lalith Chandradasa and his staff at Sarvodya for the support extended to us. We thank Dr Ravi Rannan Eliya, Director IHP for all the support and facilities extended to the team to conduct this study. Finally, we thank Mr P Christian and staff of IHP who helped us in numerous ways to complete this research study within a short period of time.

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Content page Content page .......................................................................................................................................... iii

List of tables ............................................................................................................................................ v

List of figures .......................................................................................................................................... x

List of abbreviations .............................................................................................................................. xi

Executive Summary .............................................................................................................................. xii

1. Introduction ..................................................................................................................................... 1

1.1. Background: ............................................................................................................................ 3

1.2. Justification: ............................................................................................................................ 6

2.Methodology ........................................................................................................................................ 8

2.1 Sample design ......................................................................................................................... 8

2.2 Sample Coverage and response rate ...................................................................................... 11

2.3 Pre-testing of draft questionnaires .............................................................................................. 12

2.4 Survey Period .............................................................................................................................. 12

3 Data Tabulation and Analysis ....................................................................................................... 13

3.1 Data extraction ..................................................................................................................... 13

3.2 Data entry ............................................................................................................................. 13

4 Trend analysis of treatment out comes from commencement of DOTS programme ...................... 14

4.1 Cure Rates ............................................................................................................................. 14

4.2 Default Rate ................................................................................................................................... 15

4.3 Treatment Failure Rate ............................................................................................................... 16

5. Trend Analysis by Province of treatment outcomes of TB patients ............................................. 18

5.1 Western Province .................................................................................................................. 18

5.2 Southern Province ................................................................................................................. 19

5.3 Central Province .................................................................................................................... 20

5.4 Uva Province ......................................................................................................................... 21

5.5 North Central Province ......................................................................................................... 22

5.6 Sabaragamuwa Province ....................................................................................................... 23

5.7 North Western Province ....................................................................................................... 24

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5.8 Eastern Province ................................................................................................................... 25

5.9 Northern Province ................................................................................................................. 26

6. Survey Findings and Results ......................................................................................................... 27

7. Conclusions and Recommendations ............................................................................................. 33

7.1 Recommendations ................................................................................................................ 36

8 Survey Results ............................................................................................................................... 39

9.Bibliography ....................................................................................................................................... 82

Annexes .................................................................................................................................................. 1

Annexure1: Draft Report of the workshop ............................................................................................. 2

Annexure 2: Guidelines for Administering Questionnaires .................................................................... 6

Annexure 3: Consent Form for the Patients ......................................................................................... 10

Annexure 4: Questionnaire No:1 for the TB Patients ........................................................................... 13

Annexure 5: Questionnaire No. 2 for defaulters ................................................................................. 29

Annexure 6: Questionnaire No: 3 for the DOTS Providers ................................................................... 48

Annexure 7: District Survey Teams ...................................................................................................... 63

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List of tables Table 1: TB case Detection by Districts 2009 ........................................................................................ 2

Table 2:Treatment Outcome of New sputum-smear positive PTB Cases registered in Q1, Q2 and Q3 of2008 ..................................................................................................................................................... 9

Table 3: Allocation of Sample and Coverage ....................................................................................... 11

Table 4: Response rates by District....................................................................................................... 11

Table 5 Relationship between age distribution and treatment outcome............................................... 39

Table 6 Relationship between sex distribution and treatment outcome. ............................................... 40

Table 7 Relationship between ethnicity and treatment outcome. ......................................................... 40

Table 8: Analysis of the treatment outcome and level of education .................................................... 41

Table 9. Relationship between level of education and treatment outcome. .......................................... 41

Table 10: Analysis of the treatment outcome and level of education .................................................. 42

Table 11. Relationship between marital status and treatment outcome. .............................................. 42

Table 12: Analysis of the treatment outcome and marital status ......................................................... 43

Table 13.Relationship between occupation and treatment outcome. .................................................... 43

Table 14. Relationship between nature of occupation and treatment outcome. ................................... 44

Table 15. Relationship between treatment outcome and being in prison.............................................. 44

Table 16: Analysis of the treatment outcome and imprisonment ........................................................ 45

Table 17.Relationship of smoking with treatment outcome. ................................................................ 45

Table 18. Relationship of alcohol use and treatment outcome ............................................................. 45

Table 19. Relationship of use of narcotic substances and treatment outcome ...................................... 45

Table 20: Analysis of the treatment outcome and smoking habits ....................................................... 46

Table 21: Analysis of the treatment outcome and smoking habits ...................................................... 46

Table 22. Relationship between monthly income and treatment outcome. .......................................... 47

Table 23. Relationship between patients’ understanding about the disease and treatment outcome. ... 47

Table 24: Analysis of the treatment outcome and patient’s understanding about the disease ............. 47

Table 25. Relationship between mode of acquiring information and treatment outcome. ................... 48

Table 26. Relationship of impact of having TB on the occupation and to the treatment outcome ....... 49

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Table 27: Analysis of the treatment outcome and affect to the work .................................................. 49

Table 28 . The distance to the DOT center in relation to the treatment outcome ................................. 49

Table 29 . The place where the patient had to go for DOT and the distance to the DOT center (All patients) ................................................................................................................................................. 50

Table 30. Effect of the monthly income and the expenditure for each visit to the DOT center on the treatment outcome ................................................................................................................................. 51

Table 31. Relationship of the loss of income after the diagnosis of TB and the expenditure for each visit to the DOT center with the treatment outcome ............................................................................. 51

Table 32. Relationship of the treatment outcome to the time spent for each visit to the DOT center . 52

Table 33: Analysis of the treatment outcome and time spend of each visit ......................................... 52

Table 34. Relationship of mode of transport to the DOT center and the treatment outcome. .............. 53

Table 35. Relationship of the place where they had to go for DOT with the treatment outcome and daily intake of drugs. ............................................................................................................................. 53

Table 36: Analysis of the treatment outcome and where they go for DOT ......................................... 54

Table 37. Relationship of Defaulters’ travel expenditure to the DOT center with the place where they have to go for DOT. .............................................................................................................................. 54

Table 38. Relationship of the patient’s perceived need to attend at a specific time of a day to the DOT center on the treatment outcome ........................................................................................................... 55

Table 39. Relationship of the treatment outcome of those who found it difficult / impossible to attend the DOT center at a specific time with the place where they have to go for DOT. .............................. 55

Table 40. The treatment outcome in relation to whether they swallowed the tablets daily in front of the DOT provider at the time of visiting the DOT center ..................................................................... 56

Table 41. The place of the DOT center of those who did not swallow the tablets daily in front of the DOT provider at the time of visiting. .................................................................................................... 56

Table 42.Treatment outcome in relation to frequency of DOT ............................................................ 57

Table 43. Point of default after initiation of treatment in relation to the frequency of DOT ................ 57

Table 44. Reasons given by patients for non daily DOT during the course of treatment (IP / CP / IP + CP) ........................................................................................................................................................ 58

Table 45. Reasons for the patient to request the drugs to be taken home among those with different treatment outcomes ............................................................................................................................... 58

Table 46 .The views of the patients regarding the need to visit DOT center daily for treatment with different treatment outcomes. ............................................................................................................... 59

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Table 47. Reasons for defaulting as stated by the defaulters who have said that the need to visit DOT center daily for treatment is very good and acceptable & good but not always ................................... 59

Table 48. Relationship of the awareness & the development of side effects to the treatment outcome60

Table 49: Analysis of the treatment outcome and awareness of side effects ....................................... 60

Table 50: Analysis of the treatment outcome and development of side effects ................................... 60

Table 51. Relationship of the response to the side effects of the patients who had developed side effects to treatment. ............................................................................................................................... 61

Table 52. Relationship of stigma to the treatment outcome .................................................................. 61

Table 53. Perception on DOT of the patients with different treatment outcomes ................................ 62

Table 54. Treatment outcome in relation to the family support to the patient ...................................... 62

Table 55: Analysis of the treatment outcome and with whom patient living with .............................. 63

Table 56.Awareness of the family members that the patient was suffering from TB in relation to the treatment outcome ................................................................................................................................. 63

Table 57: Analysis of the treatment outcome and awareness of the family ......................................... 64

Table 58. Patient perception regarding the family support in relation to the treatment outcome ......... 64

Table 59: Analysis of the treatment outcome and family support ....................................................... 65

Table 60. Reasons given by defaulters for not completing the whole regimen of treatment ................ 65

Table 61. Reasons for seeking treatment again (for Cat 2) after defaulting ......................................... 66

Table 62 . Patients’ views with regard to the prevention of defaulting of treatment ............................ 66

Table 63. Patients’ perception regarding the need of visiting the chest clinic regularly in relation to the treatment outcome ........................................................................................................................... 67

Table 64. Reasons given why regular chest clinic visits are necessary ................................................ 67

Table 65. Reasons given why regular chest clinic visits are not necessary. ......................................... 68

Table 66 .Patients’ suggestions to improve compliance. ...................................................................... 68

Table 67. Relationship between consulting a private doctor and treatment outcome. .......................... 69

Table 68.Education level of the DOT providers ................................................................................... 69

Table 69. Employment classification of the DOT providers of the different positions ........................ 69

Table 70.Relationship of the training of the DOT provider to the period of been involved as a supervisor in the programme ................................................................................................................ 70

Table 71. Modular training experience of DOT providers ................................................................... 70

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Table 72: Analysis of the trained for the dot provider and working experience .................................. 71

Table 73. Availability of DOT manuals with the DOT providers ........................................................ 71

Table 74: Analysis of attending to DOTS modular training and working experience ......................... 72

Table 75.Relationship of the knowledge on TB and DOTS strategy as perceived by the DOT provider to the period of been involved as a supervisor in the programme ........................................................ 72

Table 76: Analysis of knowledge on TB and working experience ...................................................... 73

Table 77. Relationship of familiarity with the concept of DOTS as perceived by the DOT provider to the period of had been involved as a supervisor in the programme. ..................................................... 73

Table 78: Analysis of familiarity with DOTS and working experience .............................................. 73

Table 79.Relationship of awareness of DOTS strategy as perceived by the DOT provider before being a DOT supervisor .................................................................................................................................. 74

Table 80.Mode of acquiring knowledge regarding TB by the DOT providers ..................................... 74

Table 81.DOTS providers views regarding DOTS vs. the previous methods of TB control to the period of been involved as a supervisor in the programme. ................................................................. 75

Table 82.Reasons given by the DOT providers for saying that DOTS is better than the previous method for TB control activities ........................................................................................................... 75

Table 83.a DOT providers views regarding the necessity of DOT at a DOT center for TB patients. .. 76

Table 84.b DOT providers views regarding the categories that do not need DOT at a DOT center .... 76

Table 85.Number of patients that the DOT provider is supervising at the moment to the position of the DOT provider ........................................................................................................................................ 76

Table 86.Mode of acquiring knowledge about DOTS in relation to the position of the DOT provider77

Table 87.Knowledge of the DOT provider about the disease and management as perceived by the interviewer ............................................................................................................................................ 77

Table 88. Action taken by DOT providers when patients interrupt treatment. ..................................... 78

Table 89.Frequency distribution of constraints faced or experienced in implementation of DOT at the DOT center in relation to the position .................................................................................................. 79

Table 90. The drug supply to the DOT center and the storage of drugs at the DOT center ................ 79

Table 91. Availabilty of facilities at the DOT centers in different types of government health institutions as observed by the Interviewer ........................................................................................... 80

Table 92.Maintenance of DOT registers and supervision of DOT Centers in government health institutions ............................................................................................................................................. 80

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Table 93. Frequency distribution of DOT providers in government health institutions and private hospitals ................................................................................................................................................ 81

Table 94.Average number of DOT providers working at a DOT center .............................................. 81

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List of figures

Figure 1: National TB Cure Rates before and after commencement of DOTS .................................... 14

Figure 2 National TB Default Rates before and after commencement of DOTS ................................. 15

Figure 3: National TB Treatment Failure Rates before and after commencement of DOTS ............... 16

Figure 4: Treatment Outcomes of DOTS TB patients - Western Province ......................................... 18

Figure 5 Treatment Outcomes of DOTS TB patients – Southern Province ......................................... 19

Figure 6 Treatment Outcomes of DOTS TB patients – Central Province .......................................... 20

Figure 7 Treatment Outcomes of DOTS TB patients – Uva Province................................................. 21

Figure 8 Treatment Outcomes of DOTS TB patients – North Central Province ................................. 22

Figure 9 Treatment Outcomes of DOTS TB patients – Sabaragamuwa Province ............................... 23

Figure 10 Treatment Outcomes of DOTS TB patients – North Western Province .............................. 24

Figure 11 Treatment Outcomes of DOTS TB patients – Eastern Province ......................................... 25

Figure 12 Treatment Outcomes of DOTS TB patients Northern Province .......................................... 26

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List of abbreviations ARTI- Annual Risk of Tuberculosis Infection

CAT 1- Category 1

CAT 2- Category 2

CP- Continuous Phase De- Defaulters DOT- Directly Observed Treatment DOTS- Directly Observed Treatment Short course DTCOs - District Tuberculosis Control Officers GFATM –Global Fund for AIDS Tuberculosis and Malaria GP – General Practioner IHP- Institute for Health Policy IP- Intensive Phase MDR-TB- Multi Drug Resistant Tuberculosis MoH- Ministry of Health MO- Medical Officer NGO- Non Governmental Organization NPTCCD- National Programme for Tuberculosis Control & Chest Diseases PHIs- Public health Inspectors PHMs- Public Health Midwife PTB- Pulmonary Tuberculosis SAARC- South Asian Association for Regional Cooperation TB - Tuberculosis TS- Treatment successors

TF- Treatment Failures

US $ - United States Dollars WHO- World Health Organization

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Executive Summary

The operational research study was undertaken to; evaluate the effectiveness of the national

DOTS programme and to propose alternate models to improve provision of DOTS at various

settings with the following objectives.

• Asses the treatment outcomes of the TB patients at various settings which use DOTS

& identify unsuccessful treatment out come.

• Asses the knowledge, attitudes & perceptions of patients under DOTS regarding their

treatment and to identify reasons for unsuccessful treatment

• To Asses the knowledge, attitudes & perceptions of DOT

Methods

Data was collected by perusing relevant registers reports maintained by NPTCCD at the

center and by DTCO’s at central chest clinics. i.e. District TB registers, Quarterly reports on

case detection, Quarterly reports on treatment outcome Using this data, trend analysis of

treatment out comes was compiled from commencement of the DOTS programme for all

districts

To assess the knowledge, attitudes and perceptions of patients under DOTS regarding their

treatment & to identify reasons for unsuccessful treatment outcomes A sample of patients

diagnosed as Pulmonary TB patients in the year 2008 i.e from all new sputum smear positive

cases registered 12 to 15 months prior to commencement of the study were selected.

Patients from nine districts from six provinces was selected for the study.

Target population represented more than 70% sputum positive patients reported during the

1st three quarters for the year 2008 in Sri Lanka.

Survey was carried out using an interviewer administered questionnaires by trained TB

campaign PHIs in Sinhala, Tamil, and English. Two separate questionnaires one for the

Treatment success and Treatment failure patients and the other for the defaulters was

administered. A total of 244 patients were interviewed.

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A random sample of 180 DOT providers who were active during 2008 were also surveyed by

the DTCO’s to assess the knowledge, attitudes & perceptions of DOT providers using an

interviewer administered questionnaires.

All districts survey teams were trained at a work shop before starting the survey and the

survey was carried out during the period December 2009 and February 2010.

Data entry

Data from the completed three sets of questionnaires from all the districts entered into

electronic format at IHP. Considering the similarity of the treatment success and defaulters a

single data base was created and a separate one for the DOT providers was maintained.

Special statistical package Stata 11 was used for the analysis. All the analysis and data

appending and cleaning were carried out using Stata 11.

Conclusions and Recommendations

Sri Lanka has adopted DOTS as a policy in 1996 and has, gradually expanded coverage and

is currently implemented in 22 districts.

The national cure rate which was 74.9 in the year 2000 has improved to 81.3. By the end of

2008. National Default Rate In the year 2000 was 14.9 and has come down to 6.8.In the year

2008. National Treatment Failure Rate was 0.8 in the year 2000.But had increased to 1.5.by

end of 2008.

A high percentage of patients’ educational level was observed to be low and it was noted that

a significant majority of the defaulters were those who had no formal education at all or

education up to grade 5. Highest treatment failures were also in the same level of education.

This study highlights the fact that there are a significant number of defaults among those who

have ever been imprisoned than others. Also a significant number of defaulters have dropped

out 2 months after the initiation of treatment and mostly when not under daily/weekly DOT.

It is observed that in most instances DOT as per the guidelines provided does not take place

and is not fully implemented as expected. And in most places the DOT providers did not get

the patients to swallow the tablets in front of them even though there were adequate facilities

for this purpose.

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The results clearly indicate that daily DOT throughout the course of treatment or daily DOT

in the IP with weekly DOT in the CP as laid down in the guidelines is not being practiced.

DOTS providers are varied and results showed wide variation in the knowledge attitudes and

skills of these persons. In this study 96.7% of the DOT providers were government health

staff. This study revealed that services of the large numbers of community health workers

trained as DOT providers have not been utilized. Fair percentage of the DOT providers has

used literature, mass media and other means to acquire additional knowledge. The knowledge

component of the DOT providers has been graded by the interviewer as unsatisfactory in a

significant number of providers

Mass communication and other health educational material have not played a major role in

information transfer as regards to patients.

It is believed that stigma as a challenge for TB control but we found in this study that only a

significantly low number of patients have been stigmatized.

DOT registers were not maintained uniformly in most of the DOT centers in the districts.

Written remarks or feed back reports from supervisors of the DOT centers were not available

in majority of the DOT centers surveyed.

The results do not reveal that the income of the patient and the expense to travel to the DOT

center daily had an effect on the treatment outcomes But the findings raise concerns about the

loss of income of the patients after the diagnosis of TB as they are mostly from lower socio

economic classes.

Recommendations

• Defaulters characteristics show that they are mostly from people of lower social

classes It is best that without having a generic treatment schedule, those patients who

could be classified as high risk to default should be institutionalized and treated, to

prevent the spread of the disease as well as prevent emergence of drug-resistant TB

which may pose significance danger in the future.

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• The financial benefits given to the patients should be increased as they are

economically deprived once they get the disease

• Measures to be adopted, aimed at promoting the effective utilization of the services of

already trained community health workers who are currently under utilized to provide

DOT and training of the community DOT providers be discontinued.

• Emphasis should be given to provide adequate information and education needed to

the patient and the family on individual basis to make them understand the importance

of continuing the medication by adhering to the treatment regime.

• To develop competent and committed DOT providers on the job training be provided

by their supervisors in addition to the regular formal training as DOT providers.

• The supervision at all levels should be strengthened to improve the quality of the

programme and to ensure that correct and routine recording and reporting are carried

out.

• DTCOs/PHIs should closely monitor and supervise DOT centers to improve the

provision of DOT services.

• A uniform register for DOT patients should be maintained in all districts.

• In the Western province a different strategy should be followed as against what is

happening in the rural dominated districts. Here the programme should be more

intensive with individual customized treatment plans with emphasis on one to one

basis on dissemination of the TB health education messages stressing the need for

continuation of therapy.

• Finally taking into consideration all of above to further improve the already successful

DOTS programme, The study team does not recommend generic models to be

adopted at various settings. Instead we recommend that time is now right to consider

possibility of implementation of individual treatment plans. The individual treatment

plans for each patient need to be decided at the time of diagnosis by the DTCO and

the PHIs .This should be done after discussing with the patient and the family

members taking into consideration the patient factors and the service delivery factors

at the respective setting.

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1. Introduction Globally, Tuberculosis (TB) infects over one third of the world’s population, causes 8 million

new cases of disease, and over 2 million deaths every year. The WHO South-East Asia

Region carries the highest burden of tuberculosis among all WHO Regions: 35% of the

global burden. Within this Region, five countries (Bangladesh, India, Indonesia, Myanmar

and Thailand) belong to the 22 TB high-burden countries, which contribute 80% of the global

case load. Another SAARC Member country, Pakistan, belongs to the 22 high-burden

countries, but is located in the WHO Eastern Mediterranean Region. India alone contributes

20% of the global disease burden.

Sri Lanka is not among the high-burden countries. However, tuberculosis remains a

widespread problem and poses a continuing threat to the health and development of the

people.

It is estimated that about 60% of adults and 45% of the general population have been infected

with the disease. The annual risk of tuberculosis infection (ARTI) is falling slowly, with the

decline estimated at about 2% per year. The highest rates of infection have been found in the

most densely populated areas, such as Colombo and other urban areas.

In 2007 there were 11676 cases of tuberculosis estimated in Sri Lanka i.e. 60 per 100,000

population. Estimated Incidence of new sputum smear positive tuberculosis was 27 per

100,000 population in 2007. The estimated prevalence in the same year is 79 per 100,000

population.

The WHO-recommended strategy for for TB control is the Stop TB . "Directly Observed

Treatment, Short-course" (DOTS) which remains as the number one component of this

strategy includes five basic key elements:

Political commitment with increased and sustained financing;

Case detection through quality-assured bacteriology;

Standardized short-course chemotherapy with supervision and patient support;

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Table 1: TB case Detection by Districts 2009

An effective drug supply and management system;

5. Monitoring and evaluation system and impact measurement

Once patients with infectious TB (bacilli visible in a sputum smear) have been identified

using microscopy services, health and community workers and trained volunteers observe

and record patients swallowing the full course of the correct dosage of anti-TB medicines

(treatment lasts six to eight months). The 1st line anti-TB drugs are Isoniazid, Rifampicin,

Pyrazinamide, Streptomycin and Ethambutol.

Sputum smear testing is repeated after two months to check progress, and again after 5

months and at the end of treatment. A recording and reporting system documents patients'

progress throughout, and the final outcome of treatment.

• DOTS produces cure rates of up to 95 percent even in the poorest countries.

• DOTS prevents new infections by curing infectious patients.

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• DOTS prevents the development of MDR-TB by ensuring the full course of treatment

is followed.

• A six-month supply of drugs for DOTS costs US $14 per patient in some parts of the

world. The World Bank has ranked the DOTS strategy as one of the "most cost-

effective of all health interventions."

Since DOTS was introduced on a global scale, millions of infectious patients have received

effective DOTS treatment. In half of China, cure rates among new cases are 96 percent. In

Peru, widespread use of DOTS for more than five years has led to the successful treatment of

91 percent of cases.

By the end of 1998, all 22 high burden countries which bear 80% of the estimated incident

cases had adopted DOTS. 43 percent of the global population had access to DOTS, double

the fraction reported in 1995. In the same year, 21 percent of estimated TB patients received

treatment under DOTS, also double the fraction reported in 1995.

In 2005, an estimated 60% of new smear-positive cases were treated under DOTS – just short

of the 70% target. Treatment success in the 2004 DOTS cohort of 2.1 million patients was

84% on average, close to the 85% target. However, cure rates in the African and European

regions were only 74%. The 2007 WHO report Global TB Control concluded that both the

2005 targets were met by the Western Pacific Region, and by 26 individual countries

(including 3 of the 22 high-burden countries: China, the Philippines and Viet Nam.

1.1. Background: Sri Lanka adopted DOTS as a policy in 1996 and implemented initially in Galle district in

1997. It was then, gradually expanded into other districts. Currently it’s been implemented in

23 districts but due to conflict situation in Kilinochchi, Mulativu and Mannar districts DOTS

was not implemented even up to the end of 2008.

Order of implementation:

1997 - Galle

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1998 - Kandy

1999 - Anuradhapura, Colombo, Matara

2000 - Kurunegala, Ratnapura, Kalutara, Puttalam

2001 - Hambantota, Kegalle, Polonnaruwa, Gampaha

2004 - Nuwaraeliya, Matale, Badulla, Moneragala, Vavuniya

2005 - Trincomalee, Batticaloa, Ampara,Kalmunai, Jaffna

There are number of DOT centres located at various settings in a single district.

• Government Sector

o Teaching Hospitals

o Base Hospitals

o District Hospitals

o Peripheral Units

o Central Dispensaries

o Other Hospitals such as Prison Hospital

• Private Sector

o Hospitals

o Dispensaries

o Healthcare workers, NGO workers, Community leaders

In these centres the treatment providers can be doctors, nurses, pharmacists, dispensers, or

any healthcare worker. Sometimes NGO workers, Gramasevaka and Religious leaders also

undertake to become direct observers of treatment.

A typical Directly Observed Treatment (DOT) Centre provides the following services,

• Direct observation of treatment

• Early detection of the side effects of treatment

• Regular health education

e.g In Colombo ideally two months requirement of drugs are delivered to the DOT centres

from the Central Chest Clinic, Colombo.

Health education of patients is usually done at the chest clinic and then by the directly

observed treatment provider.

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Training of health care personnel who are involved in DOTS is also mandatory. Training of

the Medical officers and the Primary Health Care Personnel were carried out initially in each

district prior to implementation of DOTS. Retraining was started in 2004 and it’s an ongoing

process.

Monitoring and evaluation is being carried out by collecting and collating data from the

following reports from each district; monthly, quarterly and annually.

• TB treatment card (TB-01) and patients personal records (TB Files)

• District TB register

• TB laboratory register

• Quarterly report on case finding

• Quarterly report on sputum conversion of smear positive patients at the end of

intensive phase

• Quarterly report on the results of treatment of patients registered 12-15 months earlier

• Quarterly report on microscopy activities and logistics

• Quarterly report of programme management (District level)

• Quarterly report from TB wards (District level)

• Quarterly report, Chest Hospital, Welisara

• Quarterly report, National TB reference laboratory

Based on the above routine data the following indicators are compiled and are used to

monitor the National Programme for Tuberculosis Control & Chest Diseases (NPTCCD).

• Case Detection Rate

• Case Detection Rate under DOTS

• Detection of Re-treatment TB cases

• Detection of New extra- pulmonary TB cases

• Sputum conversion rate at the end of the initial phase of treatment for new TB cases

• Sputum conversion rate at the end of the initial phase of treatment for re-treatment

TB cases

• Cure rate of new TB cases

• Cure rate of Re-treatment cases

• Treatment success rate for new smear positive pulmonary TB cases

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• Treatment failure rate for new cases

• Default rate for new cases

• Treatment success rate for re-treatment casesTreatment failure rate for re-treatment

cases

• Default rate for re-treatment cases

• Sputum smear positivity rate among all new cases

• Sputum smear positivty rate among all new pulmonary TB cases

1.2. Justification: Effective TB control depends on the rapid and accurate identification of infectious TB cases

(sputum smear positive patients) and cure of the infectious cases which is currently carried

out under DOTS. The gold standard of identifications is by examination of sputum of patients

with “cough lasting more than three weeks which is not responding to routine treatment”. In

addition to this, night sweats, low grade fever lasting, haemoptysis etc. are also taken in to

account.

NPTCCD has identified a number of DOT providing centres in each district in Sri Lanka

based on the resources available to the programme. But due to certain resource constraints

mainly human resources, there are challenges to deliver high quality DOTS services in some

districts. It was considered important to assess treatment outcome at various centres to

identify treatment failures and the reasons for those failures. In this study it was planned to

identify treatment failures at various centres taking a selected district from five provinces and

all the districts from the western province. It is envisaged that the results of this study will

help to improve the effectiveness of the National DOTS Programme in Sri Lanka.

Currently in Sri Lanka the direct observation is being carried out by health staff personnel at

district level and the services have been extended up to the lowest health institution as well as

through public health personnel. It was important to assess the knowledge, attitudes and

perceptions of treatment providers regarding DOTS, as it is noted that some times the

treatment failures may be directly attributable to quality of services provided by them.

Though ideally the treatment should be directly observed for the full course, in most

instances in Sri Lanka it is being done in the first two months of treatment because of the

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difficulties that the patient may have to face when visiting a health institution or DOTS

centres daily to swallow the drugs. The stigma attached to TB may be another reason which

prevents patients using the services of DOTS centres. Hence it is necessary to assess the

knowledge, attitudes and perceptions of patients under DOTS regarding services provided

and their adherence to treatment procedures.

Even though DOTS programme has been implemented in Sri Lanka for the past eleven years,

literature review has shown that studies to evaluate the effectiveness of national DOTS

programme on an island wide basis have not been carried out so far.

It was felt that by evaluating the effectiveness of the National Programme for DOTS and

developing alternate models to improve provision of DOTS, would lead to improvement of

the national TB control programme. Ultimately enabling the country to achieve the 100%

cure rate and prevent other people contracting this disease.

Taking into consideration of the above justification, this operational research study was

undertaken,

To evaluate the effectiveness of the national DOTS programme and to develop alternate

models to improve provision of DOTS in various settings

With the following specific objectives

1. To assess the treatment outcomes of the TB patients at various settings which use

DOTS & identify unsuccessful treatment out come by observation of records.

2. To assess the knowledge, attitudes & perceptions of patients under DOTS regarding

their treatment and identify reasons for unsuccessful treatment outcomes.

3. To assess the knowledge, attitudes & perceptions of DOT providers.

4. To develop alternate models to improve treatment success

8

2.Methodology In order to

1. Asses the treatment outcomes of the TB patients at various settings which use DOTS

& identify unsuccessful treatment out come by observation of records.

2. Asses the knowledge, attitudes & perceptions of patients under DOTS regarding their

treatment and identify reasons for unsuccessful treatment outcomes.

3. Asses the knowledge, attitudes & perceptions of DOT providers.

4. Develop alternate models to improve treatment success

Following methodology was adopted A. Relevant registers and reports maintained by NPTCCD at the center and by DTCOs at district chest clinics were accessed and studied,

i.e. District TB registers Quarterly reports on case detection Quarterly reports on treatment outcome To undertake the trend analysis of treatment outcomes from the time of introduction of national DOTS programme in the respective districts.

B. To assess the knowledge, attitudes & perceptions of patients under DOTS regarding their

treatment & identify reasons for unsuccessful treatment outcomes as well as to asses the

knowledge, attitudes & perceptions of DOT providers following procedures were adopted.

2.1 Sample design A sample of patients diagnosed as Pulmonary TB patients in 2008 were selected.

Selection of Sample

The district in each province which had the highest number of New sputum-smear positive

PTB cases was selected for the survey except the North and Uva provinces due to resource

constraints. The all three districts in the Western province were included as these districts had

the highest case load for the year 2008.

9

Target population

All new sputum smear positive cases registered 12 to 15 months prior to commencement of

the study.( 1st ,2nd and 3rd Quarters of 2008) refer table 1 below

Table 2:Treatment Outcome of New sputum-smear positive PTB Cases registered in Q1, Q2 and Q3 of2008

All defaulters and treatment failures for the year under investigation in the six districts other

than the Western province were included.

For western province all treatment failures and a sample of defaulters were selected.

From all districts equal numbers of treatment success cases were also selected for the control

group.

Target population selected represented more than 70% of sputum-smear positive PTB

patients reported during the 1st three quarters for the year 2008 in Sri Lanka.

To carry out the survey it was decided to

Administer an interviewer administered questionnaires by trained interviewers in Sinhala,

Tamil, & English. PHIs attached to the respective District Chest Clinics were selected to

complete the questionnaires for the three categories of patients.

It was thought best to administer two separate questionnaires one for the group with

Treatment success and Treatment failure patients and the other for the defaulters to obtain the

desired information.

Q 1 Q 2 Q 3 Total Q 1 Q 2 Q 3 Total Q 1 Q 2 Q 3 Total Q 1 Q 2 Q 3 TotalColombo 218 256 324 798 170 186 242 598 2 2 2 6 21 26 40 87Gampaha 114 121 162 397 83 89 127 299 1 2 2 5 10 18 19 47Kalutara 95 98 105 298 77 86 91 254 6 3 1 10 3 4 5 12Kandy 83 69 60 212 73 55 53 181 1 2 1 4 5 4 3 12Galle 54 57 55 166 49 50 50 149 0 0 0 0 0 4 3 7Trincomalee 16 20 16 52 13 20 14 47 1 0 0 1 0 0 2 2Kurunagala 55 60 67 182 40 52 53 145 0 1 4 5 8 4 3 15Anuradhapura 32 47 36 115 24 35 30 89 2 3 0 5 0 0 0 0Rathnapura 72 86 85 243 64 76 72 212 0 2 1 3 4 4 5 13

Total 739 814 910 2463 593 649 732 1974 13 15 11 39 51 64 80 195Grand Total 39

District Treatment FailureTotal No registered Cured Defaulted

1952463 1974

10

Inclusion criteria for

Questionnaire No. 1

(Target population was treatment success and treatment failures)

a) ‘New’ patients registered in the first 3 quarters in 2008 who have been treated

successfully

a) ‘New’ patients registered in the same period who have failed treatment (Re-

registered later as ‘Treatment after Failure’ and may be still on Cat II treatment at the

time of administering the questionnaire)

Questionnaire No. 2

(Target population was defaulters)

b) ‘New’ patients registered in the first 3 quarters in 2008 who have defaulted

treatment

c) ‘New’ patients registered initially in the same period who have defaulted and

returned for treatment later (Re-registered later as ‘Treatment after Default’ and

may be still on Cat II treatment at the time of administering the questionnaire)

In addition a random sample of DOT providers who were active during this period were also

surveyed to assess the knowledge, attitudes & perceptions of DOT providers.

10% of all these selected patients and DOT providers were cross checked for consistency.

Overall supervision

During the field survey in addition to the supervision of the survey carried out by the

respective DTCOs, the Team leader and the research assistant also visited all the districts and

did some field visits and cross checked data collected in some of these patients and providers

who have already been surveyed.

11

2.2 Sample Coverage and response rate Table below gives the details of the sample selected from the districts as selected above Table 3: Allocation of Sample and Coverage

Table 4: Response rates by District.

The response rates from the cured patients were good. But tracing of treatment failures was

poor. Survey found it difficult to locate these persons as they have either left the district or

had passed away. Defaulters too the problem was locating them due to non availability of

these patients at their residence even after three consecutive visits by the interviewer.

Cured Failures Defaulters Cured Failures DefaultersColombo 37 25 35 32 1 18Gampaha 27 17 25 25 4 18Kalutara 30 10 25 22 8 7Kandy 20 12 20 16 3 8Kurunagala 25 15 20 19 9 8Anuradhapura 10 0 15 5 0 0Trincomalee 4 2 10 3 1 2Rathnapura 19 13 20 13 2 5Galle 7 7 15 7 8Total 179 101 185 142 28 74

DistrictSampled Responded

Cured Failures DefaultersColombo 86.5 4 51.4Gampaha 92.6 23.5 72Kalutara 73.3 80 28Kandy 80 25 40Kurunagala 76 60 40Anuradhapura 50 - 0Trincomalee 75 50 20Rathnapura 68.4 15.4 25Galle 100 0 53.3Total 79.3 27.7 40

DistrictSampled

12

2.3 Pre-testing of draft questionnaires This was carried out at Kegalle District Chest Clinic,

Making use of:

6 Treatment success Cases

2 Treatment failure Cases

4 Defaulters

4 DOT providers

By the Team leader and the research team.. The questionnaires were further modified and

improved to get the intended results

Training of district survey teams

After selection of the districts and the samples a training work shop was conducted by the

team leader along with the research team at NPTCCD center in November 2009 for all

district survey teams. Objective of this workshop was to discuss and practice the filling of the

questionnaires and provide the survey teams with guidelines for conducting the surveys and

the sampling frame for selection of the patients. This was to ensure uniformity in the

collection of data for the study before commencing the field work in December 2009.

Participants were the DTCOs and PHIs attached to the respective districts chest clinics.

a) The work shop report .including the list of participants is given in annex 1

b) Guidance for field survey and submission of completed questionnaires and

administrative requirements were also discussed. Refer annex 2

c) Consent for participation was also to be obtained from the patients and the

consent form used is given in annex 3

d) Questionnaires administered toTB patients, Defaulters and DOT providers are

given in annexes 4,5 and 6

e) List of the District survey teams is given in annex 7

2.4 Survey Period Survey was carried out during the period of 7th December 2009 to 28th February

2010.Survey took a little longer than anticipated due to the presidential election that was held

in January 2010.

13

3 Data Tabulation and Analysis

3.1 Data extraction Data was collected from three groups namely defaulters, treatment success and DOT

providers using interviewer the administered questionnaires designed by IHP. Questionnaire

had few multiple response and few open ended questions.

3.2 Data entry The data submitted by the district survey teams ( completed questionnaires) were entered into

electronic format using Microsoft excel spread sheet. Three data entry sheets for three sets of

questionnaires were prepared initially. Considering the similarity of the treatment success and

default group questionnaires, it was decided to create a single data base and to generate new

variable to identify the respondent category. For the DOT providers questionnaire a separate

data set was maintained. Special statistical package Stata 11 was used for the analysis of both

this sets of data. All the analysis and data appending and cleaning was carried out using Stata

11. For the multiple response questions though it was required to mention the priority

accordingly respondent’s preferences most of the time it was noted that it had not been coded

correctly. Considering this draw back all the responses for multiple answers were considered

as equally important for the analysis. There were no response for some of the skip questions.

Data cleaning was carried out considering those records as if they were missing or by

applying appropriate methods. The analyses of open ended questions were done selecting

major categories considering similar types of response for each of these questions.

14

4 Trend analysis of treatment out comes from commencement

of DOTS programme Trend analysis using, cure rates, default rates and treatment failure rates were carried out

from the year 2000 to 2008 in 22 districts where the national DOTS program has been

implemented. Ampara district had two divisions reporting i.e Ampara and Kalmunai.

Following three maps depicts the national figures for the three rates used for trend analysis i.e

Cure Rate. Default rate and treatment success rate by districts.

4.1 Cure Rates Figure 1: National TB Cure Rates before and after commencement of DOTS

15

In the year 2000 ,the national cure rate was 74.9.It is observed that twelve districts had cure rates

above the national figure while one district had reached the national average. But in 7 districts cure

rates were below the national figure. At this point of time cure rate data was not taken into account in

three of the districts as data was not available. By the year 2008,the national cure rate has improved to

81.3.And there were 22 districts implementing the DOTS program. The number of districts having

cure rates above the national figure had increased up to 14 while 1 district had reached the national

average. But in 8 of the districts cure rates were still below the national average.

4.2 Default Rate

Figure 2 National TB Default Rates before and after commencement of DOTS

16

In the year 2000 the national default rate was 14.9.It is observed that in 4 districts default

rates were above the national default average while 16 districts had below national figure. By

the year 2008,the national default rate has come down to 6.8.In the year 2008 the number of

districts having default rates above the national average were 5, while those below national

level were 16.There were two districts which had reached national default rate.

4.3 Treatment Failure Rate Figure 3: National TB Treatment Failure Rates before and after commencement of DOTS

National Treatment Failure Rate was 0.8 in the year 2000. It is noted that only 3 districts had

treatment failure rates above the national figure, while 9 districts had values below national

rate. 3 districts had the same treatment failure rate as the national rate. Data from 8 districts

17

were not available at this point of time. By the year 2008, the national treatment failure rate

was 1.5. The number of districts having treatment failure rates above national rate has

increased up to 9 by 2008 though 10 districts had managed to maintain a failure rate lower

than national figure. 3 districts had same failure rates as national level while data from 1

district was not available.

18

5. Trend Analysis by Province of treatment outcomes of TB patients

The following sections gives in details the trend analysis and interpretation of these results by provinces and districts after the commencement of the DOTS programme in the country for the period 2000 to 20008

5.1 Western Province Figure 4: Treatment Outcomes of DOTS TB patients - Western Province

Western Province had the highest TB Patient load during the last decade

Cure Rates

Kalutara district shows the highest cure rates for TB while Gampaha district shows the

lowest. Cure rates have been lowest in Gampaha during the year of 2003. It has gradually

19

improved but it is still below the national average.It should be noted with concern that both

Kalutara and Gampaha rates appear to be coming down during the last three years.

Default Rates

It is important to note that default rate is seen lowest in Kalutara district throughout the years

and is below the national average. But in the other two districts in Western Province it has

been above the national average and appears to be still going up after an initial drop in 2003.

Treatment Failure Rates

Among the districts in the Western province Kalutara had the lowest treatment failure rates

up to 2004 after which the failure rate has started to rise from 2005 onwards and is well

above the national rates. This has to be further investigated.

5.2 Southern Province Figure 5 Treatment Outcomes of DOTS TB patients – Southern Province

20

Cure Rates

In the Southern Province Cure Rates are now above the national average.Hambantota has

improved after dipping below the national averages in the years 2003 and 2004

Default Rates

It is noted that the default rates had been gradually coming down up to 2005 in all districts.

The Default rate at Hambantota had increased in 2007 but still remains below the national

rates

Treatment Failure Rates.

Presently in all three districts this rate is below the national average

5.3 Central Province Figure 6 Treatment Outcomes of DOTS TB patients – Central Province

In the year 2001 a low cure rate and a high default rate was seen in the Matale district with a

high rate of treatment failures in 2006 and 2008.But the default rate is now satisfactory and is

21

below the national averages. The cure rate which was very high in 2003 appears to be

decreasing now. There seems to be a general increase in treatment failures towards the latter

part of the decade in the Central province has come below the national rates in 2007 but again

it appears to be going up in 2008. Default rates has been below the national rates after 2003

except for Nuwara Eliya where it has gone up above the national average in 2005 and 2006.It

has again dipped below the national average in 2008.

5.4 Uva Province Figure 7 Treatment Outcomes of DOTS TB patients – Uva Province

Data from Monaragala district for the early part of the decade was not available

Cure Rates

In the Uva Province Cure rates which were below the national average in the period 2003 to

2005 went above the national average in 2007 but again seems to be coming down in 2008.

Default rate is far below the national rates.

22

Treatment Failure rate after being below the national average from 2003 to 2007 had gone

up in 2008 in both districts

5.5 North Central Province Figure 8 Treatment Outcomes of DOTS TB patients – North Central Province

Within the North Central province Anuradhapura district has maintained high cure rates and

low default rate through out. It is noted that there has been a rise in treatment failures in the

latter part of the decade. In the Polonnaruwa district where the cure rates has been below

national figures for many years has gone above the national average since 2005.Default rates

in both districts are now very low and below the national averages.

23

5.6 Sabaragamuwa Province Figure 9 Treatment Outcomes of DOTS TB patients – Sabaragamuwa Province

Kegalle district has maintained higher cure rates than national figures throughout the years. It is

important to note that in Ratnapura there have been high failure rates during the years of 2000 and

2006. It has now come down below the national average in 2007. Defaulter rates has come down

gradually during the period 2002 to2006 but now appears to be on the rise in both districts. In

Ratnapura where the default rate had been very high since 2000 showed a decline in 2006 but has

started to increase in 2007/8.

24

5.7 North Western Province Figure 10 Treatment Outcomes of DOTS TB patients – North Western Province

In Kurunagela district there has been a rise in the cure rate and was equal to the national

average in 2008. But in Puttalam the rate is still below the national average. In Kurunagela

the default rate is below the national averages but appears to have increased in 2008. In

Puttalam it is high.Treatment failure rates have been satisfactory in both districts but in the

year 2007 in Kurunagela it has gone far above the national average..

25

5.8 Eastern Province Figure 11 Treatment Outcomes of DOTS TB patients – Eastern Province

In Batticloa cure rates have been persistently lower than national figures throughout the years

but is observed to be gradually improving. It has the highest default rates for the province and

far above the national average. Batticloa reports a default rate as high as 20% in 2007

although no failures are reported during this period. Trincomalee district shows variable cure

and failure rates throughout the decade with a sudden increase in the failure rate during 2006.

Ampara and Kalmunai health divisions in Ampara district show increases in failure rate in

2006 to 2008.

26

5.9 Northern Province Figure 12 Treatment Outcomes of DOTS TB patients Northern Province

In the Northern Province cure rates have been below national figures throughout the decade but now appears to be improving and has reached national average by 2007.In Jaffna it has gone above this in 2008. Vavuniya district where initially the default rate was very high now reports a decline and is below the national average. There is no reporting of failures throughout the decade in Vavuniya . The Treatment failures in Jaffna which had been rising from 2003 to 2005 shows a sudden drop in 2006 .

27

6. Survey Findings and Results

To assess the knowledge, attitudes & perceptions of patients under DOTS regarding their

treatment & identify reasons for unsuccessful treatment outcomes, a sample of patients

diagnosed as sputum smear-positive pulmonary TB patients in 2008 were selected and

surveyed using two questionnaires. To assess the knowledge, attitudes & perceptions of DOT

providers a random sample of DOT providers who were active during 2008 were also

surveyed using a questionnaire.

The survey was conducted in six provinces. The age breakdown of the patients in the study

sample correspond with the age breakdown of the sputum smear positive TB patients

reported nationally where the highest number of patients are found between the age group of

45 – 54 years (Annual report – 2007, National Programme for Tuberculosis Control and

Chest Diseases). Significant differences between the treatment outcome categories among the

different age groups were not found (Table 5). Among the TB patients surveyed more males

were seen than the females with a ratio of 3.3 : 1 (Table 6). Most of the patients in the survey

were Sinhalese and there does not appear to be any significant increase in any treatment

outcome category as these are closer to the national ethnic distribution (Table 7). Higher

percentage of patients’ educational level was observed to be low and it is noted from the

results of the survey that majority of the defaulters (63.5%) were those who had no formal

education at all or education up to grade 5. Highest treatment failures were also in the same

level of education (Table 9). 80.7% of the study population were married and a significant

difference in treatment outcome categories were not seen (Table 11).

This study shows that there was a tendency for those employed or self employed to default

and the highest rates were among the unskilled labourers (Table 13 &Table 14). It is

observed that the impact of having TB on the occupation with inability to attend work daily

was mostly among the defaulters (Table 26). This study highlights the fact that there is a

significant number of defaults among those who have ever been imprisoned than others

(Table 15). Both defaults and treatment failures were high among those in the lower income

groups (Table 22).

28

The results do not reveal that the income of the patient and the expense to travel to the DOT

center daily had an effect on the treatment outcomes (Table 30). But the findings raise

concerns about the loss of income of the patients after the diagnosis of TB (Table 31) which

is likely to cause greater economic and social impact on their families. Most of the DOT

centers were accessible and convenient to the patients with regard to the distance, mode of

transport and the time spent for each visit (Table 28,Table 32 & Table 34). We observed that

these factors have no effect to the unfavourable treatment outcomes.

In Sri Lanka in principle all components of the DOTS strategy has been accepted and is being

implemented, but we found that DOT is not fully implemented as expected. In this study it

was revealed that the drug intake of 22.5% of the patients had not been supervised and the

patients had not swallowed the drugs under the watchful eyes of the treatment supervisor

(DOT provider). Also it is worth to note that most of the patients whose drug intake had not

been supervised were those attending DOT centers in the government institutions (Table 41

& Table 42). Significantly fewer numbers were identified as having their DOT providers as

community volunteers, family member, GP and others. The burden of observing patients

taking their medication while attending on their routine work has been stated as a constraint

faced by 16.7% of the DOT providers (Table 89). Such patients may have received lower

quality of care. Even though they had visited the DOT center daily they might not have

received the care that was expected.

This study reveals that 98.6% of the DOT providers are government health staff and most of

them had educational levels above Grade 10 (Table 68). It is observed that in the government

institutions, dispensers (30.5%) were the main category recruited as DOT providers (Table

69). The next highest category was found to be the nursing officers (22.8%). In this sample

the number of minor staff serving as DOT providers was 37 (15%) which is still significant.

The involvement of the PHMs and PHIs are 4.5% & 5.7% respectively and less than the

involvement of minor staff and even pharmacists (22%). This study shows that the services of

the large numbers of community health workers trained as DOT providers have not been

utilized. Most of the government DOT centers had an average of 4 trained DOT providers

per center.

29

Majority of the DOT providers (88.3%) were trained for the task but we found that a

significant proportion had not attended modular training even though some of them have

functioned as DOT providers for more than 4 years. Only 54.4% of the DOT providers had

the manual with them although 63.3% had been trained on the module (Table 70, Table 71 &

Table 73). 72.4 % of the Govt. health staff has acquired knowledge regarding TB from the

DOTS training. But it is observed that only 16.7% in the other group has benefitted from

DOTS training. Significant numbers of the DOT providers has used literature, mass media

and other means to acquire additional knowledge (Table 80).

It is observed that out of the 16.1% who are not familiar with concept of DOTS, 55% had

been in the programme for more than 4 years (Table 77). The knowledge component of the

DOT providers has been graded by the interviewer as unsatisfactory in a significant number

of providers and mostly on treatment categories & regimen and on the awareness of the side

effects. Very few numbers have been graded as highly satisfactory (Table 87).

Despite the documented benefits of daily DOT we found that there are no defaulters among

those who attended DOT center weekly during both intensive and continuation phases (Table

42). We observed that a significant number of defaulters have dropped out 2 months after the

initiation of treatment and mostly when not under daily/weekly DOT (Table 43). The results

clearly indicate that daily DOT through out the course of treatment or daily DOT in the IP

with weekly DOT in the CP as laid down in the guidelines (Page 82, General Manual for

Tuberculosis Control-January 2005) is not being practiced. In most instances patients have

requested to take drugs home and the most frequently occurring reasons as expressed by them

were “it is easy”, “nature of occupation” and difficulty in transport”(Table 33). Patients’

dissatisfaction with attending the DOT center daily (Table 46) and attending the DOT center

at a specific time of the day (Table 38) was observed only in a small proportion of patients.

Though a significant number of DOT providers expressed their views as DOT at a DOT

center was not necessary for professionals and health workers (Table 84) it is not possible to

predict at the commencement of treatment which patient will adhere to treatment till the end.

An observation made was that 51.4% of defaulters feel that the need to attend the DOT

center daily is ‘very good and acceptable’ or ‘good but not always’ (Table 46) but had

dropped out due to various other reasons which are discussed later in this report.

30

DOT is being perceived by a significant number of patients (52%) as ‘necessary for all

patients’ with a high proportion of treatment failures within that. Need of a supervisor to take

care of themselves were also felt by most of the treatment failures (table 53). Most of the

DOT providers stated that cure rates were higher with DOTS and patient compliance was

better (Table 82).

The key factor in the success of DOTS is the uninterrupted supply of drugs to the DOT

centers. Although the drug supply in most of the DOT centers were satisfactory, still the drug

supply to 3.4% of the government DOT centers has not been satisfactory (Table 90). It has

been observed that drugs were out of stock at 8 centers in the government sector and one non-

government DOT center.

Drug storage has not been maintained as expected to be in 14 (8 %) government DOT

centers but in the private DOT centers it was better. Drugs have not been kept under lock and

key in 58(33%) of government DOT centers and in 3 out of 6 private DOT centers (Table

90).

High proportion, 85.9% of the treatment successors and 89.3% of the treatment failures have

perceived that they had a good understanding about the disease. But it was only 50% among

the defaulters who thought that they had a good understanding of the disease (Table 23). It is

observed that significant number of defaulters have stopped medication because they felt

better and the reappearance of the symptoms was found as the main reason for them to seek

care again after defaulting (Table 60 & Table 61). With respect to the mode of education of

the patients we found that 65.4% had been educated at a chest clinic by Medical Officers.

Mass communication and other health educational material have not played a major role in

information transfer (Table 25).

Awareness of the side effects by the patient has been beneficial in that the majority of

patients had sought medical advice while continuing treatment (Table 48 & Table 51). It is

believed that stigma as a challenge for TB control but we found in this study that only a

significantly low number of patients have been stigmatized. The numbers stigmatized are

high among the defaulters. An interesting finding was that substantially high proportion is

stigmatized by family (Table 52).

31

This study revealed that 67.6% of the patients in the sample had been living with the spouse

and 16% with other relatives. 6.6% have been living alone and 75% out of them have

defaulted These findings in the study corroborate the fact that the family support to the

patient has an effect on the treatment outcome by having a significant difference in the

proportion of treatment successors living with the spouse and those living alone (Table 40).

The study revealed that none of the treatment successors or treatment failures had said that

the family support was poor but 17.6% of the defaulters have said that it was poor (Table

58).

The results show that there is a need to accelerate the current effort to decentralize the

treatment centers and to extend the DOT services to the community level. Higher proportion

of the patients (68.4%) felt that regular chest clinic visits were not necessary (Table 63) and

when needed it was for only sputum microscopy and investigations (Table43). A significant

proportion of all patients 34.5% has suggested distributing the drugs closer to the home for

improving compliance. Most of the treatment successors and treatment failures were of this

view, while most of the defaulters have suggested minimizing travel for better compliance

(Table 64). A High proportion of defaulters has also suggested ‘DOT at home’ and ‘Drugs

to be provided to the patient’ to reduce default (Table 62). It is observed that the non-

government DOT providers had gone to the patients’ residences and traced them when they

interrupted treatment while informing the relevant personnel and hence are more likely to

prevent defaulting than government DOT providers (Table 88).

We recognized the constraints faced by the DOT providers in providing quality services to

the patients. The main problems encountered were the poor facilities at the DOT centers,

difficulty in tracing the patients once they interrupt treatment and poor cooperation of the

patients (Table 89).

DOT registers were not maintained in a fair number (34.5%) of the DOT centers and there

was no uniformity of recording in these registers in most of the centers .It is noted that the

treatment cards have been updated daily in a very high proportion of DOT centers. But

written remarks or feedback reports from supervisors of the DOT centers were not available

in most of the DOT centers surveyed (Table 92). This is a reflection of the inadequate

supervision of the DOT centers by the DTCO/PHI.

32

This study had limitations. Due to the resource constraints the study was limited to six out of

the nine provinces in the country. We identified the PHIs attached to the chest clinics as data

collectors since they were the most suitable persons to trace the patients and administer the

questionnaire within the limited time period we had for conducting the survey. But this would

have created some bias on certain factors identified.

33

7. Conclusions and Recommendations

Sri Lanka has adopted DOTS as a policy in 1996 and implemented national DOTs

programme initially in Galle district in 1997. It was then, gradually expanded into other

districts. Currently it’s been implemented in 22 districts. Implementation had not been

possible due to the conflict situation that existed up to May 2009 in Kilinochchi, Mulativu

and Mannar districts. Trend analysis using, cure rates, default rates and treatment failure

rates were carried out to assessed the effectiveness of the National DOTs programme

The national cure rate was 74.9 in the year 2000 and by the year 2008, the national cure rate

has improved to 81.3. But it is observed that in 8 of the districts, cure rates were still below

the national average. National Default Rate In the year 2000 was 14.9. By the year 2008, the

national default rate has come down to 6.8.In the year 2008 the number of districts having

default rates above the national average were only 5. National Treatment Failure Rate was

0.8 in the year 2000.By the year 2008; the national treatment failure rate had increased to 1.5.

The number of districts having treatment failure rates above national rate was 9 in the year

2008.

In Colombo and Gampaha districts the cure and default rates were below the national

average. They also have the highest patient load and concerted efforts need to be carried out

to improve implementation of DOTS to have an impact on the national averages. In this

survey that was conducted in six provinces the age breakdown of the patients in the sample

corresponded with the age breakdown of the sputum smear positive TB patients reported

nationally Most of the patients in the survey were Sinhalese and there does not appear to be

any significant increase in any treatment outcome category as these are closer to the national

ethnic distribution

The patient’s characteristics show that certain groups of people are vulnerable to the diseases

in Sri Lanka which is also noted from other country findings as well. A high percentage of

patients’ educational level was observed to be low and it was noted that a significant majority

of the defaulters were those who had no formal education at all or education up to grade 5.

Highest treatment failures were also in the same level of education. Also this study

highlights the fact that there is a significant number of defaults among those who have ever

34

been imprisoned than others. Both defaults and treatment failures were high among those in

the lower income groups.

Also a significant number of defaulters have dropped out 2 months after the initiation of

treatment and mostly when not under daily/weekly DOT. These findings indicate that there is

a need for continuous monitoring of the patients with frequent contact to ensure that they

adhere to treatment Inmates at detention centers and prisons should be monitored to detect

early cases of TB and prevent the spread of the disease in these places of residences.

Additional interventions are needed to reduce default among those who have been

imprisoned.

It is observed that in most instances DOT as per the guidelines provided does not take place.

This study and our field observations and discussions with the field staff revealed that DOT is

not fully implemented as expected. In spite of the word DOT meaning that the patient

swallows the drugs under the watchful eyes of the treatment supervisor, most places do not

insist that the patients swallow the tablets in front of them even though there are adequate

facilities for this purpose. This short coming was noted even during the treatment of patients

in the intensive phase. The results clearly indicate that daily DOT through out the course of

treatment or daily DOT in the IP with weekly DOT in the CP as laid down in the guidelines is

not being practiced. The DOT have been followed according to the whims and fancies of the

DOT provider some times weekly some times once in three days and some times even longer

duration with drugs provided to the patient to take to homes and take their medications at

home with out adequate supervision.

For Intensive period it is essential that DOT as per the guidelines should be given and this

can be relaxed during the next phase after correct assessment of the patient. But every effort

should be made not to extend beyond weekly DOT as there were more defaulters among

those who had DOT other than daily or weekly in the continuation phase. DOTS providers

are varied and results showed wide variation in the knowledge attitudes and skills of these

persons. In this study 96.7% of the DOT providers were government health staff. It was

observed that DOT provided at places where dispensers do the work is not the best. As far as

possible it is best that this task be given to nurses. This study shows that services of the large

numbers of community health workers trained as DOT providers have not been utilized. Most

of the DOT providers were trained for the task but we found that a significant proportion had

35

not attended modular training even though some of them have functioned as DOT providers

for more than 4 years. Fair percentage of the DOT providers has used literature, mass media

and other means to acquire additional knowledge.

The findings of the study address the need for continued capacity building of the DOT

providers both in the government and non-government sector. The knowledge component of

the DOT providers has been graded by the interviewer as unsatisfactory in a significant

number of providers and mostly on treatment categories & regimen and on the awareness of

the side effects. Very few numbers have been graded as highly satisfactory .A vast

knowledge of the subject is not necessary but they should be able to give guidance regards to

the disease, side effects and should have the basic knowledge of the variety of drugs used and

the treatment schedule. Complex issues could always be referred to the Central Chest Clinics.

In most instances patients and a significant numbers of the DOT providers has used literature,

mass media and other means to acquire additional knowledge.

Mass communication and other health educational material have not played a major role in

information transfer as regards to patients. The findings reinforce that adequate information

and education needs to be provided to the patient and the family on individual basis to make

them understand the importance of continuing the medication by adhering to the treatment

regime prescribed.

It is believed that stigma as a challenge for TB control but we found in this study that only a

significantly low number of patients have been stigmatized. The numbers stigmatized are

high among the defaulters. An interesting finding was that substantially high proportion is

stigmatized by family members and relatives. Therefore it is necessary to adopt measures to

educate the family members. It was also observed during the field supervision that patients

were more stigmatized by the higher social classes rather than the low as they felt threatened

through inadequate knowledge they had gained and hence educational thrusts should also be

focused on this aspect as there are patients from this sector as well.

DOT registers were not maintained uniformly in most of the DOT centers in the districts.

Written remarks or feed back reports from supervisors of the DOT centers were not available

36

in majority of the DOT centers surveyed. Logistical constraints at DOT centers need to be

addressed by the MoH/NPTCCD to facilitate the delivery of quality care and DTCOs should

closely monitor and supervise these DOT centers to improve the provision of DOT services at

these centers.

Although the results do not reveal that the income of the patient and the expense to travel to

the DOT center daily had an effect on the treatment outcomes But the findings raise concerns

about the loss of income of the patients after the diagnosis of TB which is likely to cause

greater economic and social impact on their families as these patients are mostly from lower

socio economic classes.

The key factor in the success of DOTS is the uninterrupted supply of drugs to the DOT

centers. Although the drug supply in most of the DOTS centers were satisfactory but still the

drug supply to a few government DOT centers had not been satisfactory. In these centers

drugs have been out of stock for more than one month .

7.1 Recommendations • Defaulters characteristics show that they are mostly from people of lower social

classes who are unreliable and it is best that with out having a generic treatment

schedule, those patients who could be classified as high risk to default should be

institutionalized and treated in the best interest of the community as they can spread

the disease as well as transform the disease to drug-resistant TB and pose significance

danger in the future even though this is not a major concern at present.

• Special attention should also be paid to inmates at detention centers and prisons and

they should be monitored to detect early cases of TB and prevent spread of the

disease in their places of residences. The program should concentrate on having

additional interventions to reduce the prisoners defaulting treatment.

• The financial benefits given to the patients should be increased as they are

economically deprived once they get the disease as well as they come mainly from the

poor strata of the community. Some does not have adequate finances to go even to

the closest DOT center provided, which are far and wide due to escalating transport

costs.

37

• Findings in the study corroborate the fact that the family support to the patient has an

effect on the treatment outcome by having a significant difference in the proportion of

treatment successors living with the spouse and those living alone In this regard it is

recommended to adopt measures aimed at promoting the effective utilization of the

services of the already trained community health workers who are currently under

utilized to provide DOT. This will improve patient compliance and reduce default.

• Further training of the community DOT providers need to be discontinued.

• Mass communication and other health educational material have not played a major

role in information transfer. The findings reinforce that emphasis should be given to

provide adequate information and education needed to the patient and the family on

individual basis to make them understand the importance of continuing the

medication by adhering to the treatment regime prescribed as mass media approach

has not had the desired effects.

• The knowledge component of the DOT providers has been found to be inadequate.

The findings of the study address the need for continued capacity building of the DOT

providers both in the government and non-government sector. It is recommended that

in order to develop competent and committed DOT providers they should be provided

on the job training by their supervisors in addition to the regular formal training as

DOT providers.

• The supervision at all levels need strengthening to improve the quality of the

programme and to ensure that correct and routine recording and reporting are carried

out. Logistical constraints at DOT centers need to be addressed by the MoH/NPTCCD

to facilitate the delivery of quality care at DOT centers and DTCOs/PHIs should

closely monitor and supervise these DOT centers to improve the provision of DOT

services. Supervisors should provide a written feed back after their supervisory visits

to these centers.

38

• A uniform register for DOT patients should be maintained in all districts. The disease

being more a problem in the urban setting it is found that large number of cases are

from the Western province mainly in Colombo district with large number of

defaulters as well. A different strategy to overcome this problem should be followed

as against what is happening in the rural dominated districts. Here the programme

should be more intensive with individual customized treatment plans with emphasis

on one to one basis on dissemination of the TB health education messages stressing

the need for continuation of therapy.

• Finally taking into consideration all of above to further improve the already successful

DOTS programme, we do not recommend generic models to be adapted at various

settings. Instead we recommend that time is now right to consider possibility of

implementation of individual treatment plans taking into consideration both the

patients and service delivery factors in various settings.

• We feel that the flexible nature of DOTS strategy will enable the health worker to

adapt innovatively to the best model to suit the patient’s interest. Therefore the plan of

action for each patient need to be decided at the time of diagnosis by the DTCO and

the PHIs .This should be done after discussing with the patient and the family

members taking into consideration the patient factors and the service delivery factors

at the respective setting to minimize defaulting and to ensure that they strictly adhere

to daily intake of drugs.

39

8 Survey Results Introduction Chi square test and Fisher’s exact test was used to test the statistical relationship between two

groups of the treatment outcome and other interest variable. As a rule of thumb if the

observed number of any cell is less than 5 Fisher’s exact has been used for the significant

test.Some of the data tables were regrouped for significant tests in order to get sufficient

numbers for some categories. Those who did not respond to the questions were excluded

from the statistical analysis.

As chi square test or Fisher’s exact test is not able to identify which category/categories have

the significant relationship and the direction of the relationship to the treatment outcome,

standardized residual has been calculated for identified relevant categories.

Table 5 Relationship between age distribution and treatment outcome.

Source: IHP TB survey 2009 Majority of the patients in the sample were in the ages between 25 and 65. Out of them

29.9% of patients were between 45 and 54 years of age, while only 2% and 0.8% were in the

age groups below 15 years and above 75 years respectively.

% Number % Number % Number % Number <15 2.1 3 3.6 1 1.4 1 2 515-24 12 17 0 0 1.4 1 7.4 1825-34 17.6 25 7.1 2 12.2 9 14.8 3635-44 12 17 17.9 5 27 20 17.2 4245-54 24.6 35 35.7 10 37.8 28 29.9 7355-64 20.4 29 17.9 5 17.6 13 19.3 4765-74 9.2 13 17.9 5 2.7 2 8.2 20>75 1.4 2 0 0 0 0 0.8 2Not responded 0.7 1 0 0 0 0 0.4 1Total 100 142 100 28 100 74 100 244

Age Distribution

(Years)

Treatment outcomeTotalTS TF De

40

Table 6 Relationship between sex distribution and treatment outcome.

Source: IHP TB survey 2009 These results indicate that there is no statistically significant relationship between the

treatment outcome and gender (chi-square with two degree of freedom = 15.7631, p =

0.000).

Most of the patients in this survey were males 77 % .It is observed that males were in the

majority in all treatment outcome categories and contributed to 68.3%, 82.1%and 91.9% to

the treatment successors, failures and defaulters respectively.

Table 7 Relationship between ethnicity and treatment outcome.

Source: IHP TB survey 2009

Majority of the patients sampled in the study were Sinhalese while Tamil and Muslim

participation is 13.9% and 10.2% respectively. There does not appear to be any significant

increase in any category as these are closer to the national ethnic distribution.

% Number % Number % Number % NumberMale 68.3 97 82.1 23 91.9 68 77.0 188Female 31.7 45 17.9 5 8.1 6 23.0 56Total 100.0 142 100.0 28 100.0 74 100.0 244

Sex Distribution

Treatment outcomeTotalTS TF De

% Number % Number % Number % NumberSinhalese 78.9 112 78.6 22 66.2 49 75 183Tamil 11.3 16 14.3 4 18.9 14 13.9 34Muslim 8.5 12 7.1 2 14.9 11 10.2 25Burgher 1.4 2 0 0 0 0 0.8 2Total 100 142 100 28 100 74 100 244

Ethnicity

Treatment outcomeTotalTS TF De

41

Table 8: Analysis of the treatment outcome and level of education

Note: standardized residual values (z) in parenthesis.

Source: IHP TB survey 2009 These results suggest that there is a no statistically significant relationship between treatment

outcome and ethnicity (p = 0.255). Table 9. Relationship between level of education and treatment outcome.

Source: IHP TB survey 2009 Educational level of the patients in the sample was low. 46.1% had no formal education or

was educated up to grade 5. 18.5% of study population has had no formal education and they

contributed to 27% and 17.9% to default and failure rates respectively. Only 1.2 % of the

study population had undergone tertiary education and there were no reported defaulters or

treatment failures among them. Highest treatment failures were seen amongst the patients

with no formal education and educated up to grade 5 (60.8%).Similarly in the default

category they contributed to 63.5 % of the defaulters.

TS TF DeSinhalese 112 22 49

(0.60) (0.18) (-0.93)Tamil 16 4 14

(-0.83) (0.03) (1.12)Muslim 12 2 11

(-0.65) (-0.52) (1.21)Fisher's exact = 0.255

EthnicityTreatment outcome

% Number % Number % Number % Number No formal education 14.1 20 17.9 5 27 20 18.4 45Up to Grade 5 19.7 28 42.9 12 36.5 27 27.5 67Up to Grade 10 19.7 28 21.4 6 28.4 21 22.5 55Up to O/L 24.6 35 7.1 2 5.4 4 16.8 41Up to A/L 18.3 26 7.1 2 2.7 2 12.3 30Tertiary education 2.1 3 0 0 0 0 1.2 3Other 0.7 1 3.6 1 0 0 0.8 2Not Responded 0.7 1 0 0 0 0 0.4 1Total 100 142 100 28 100 74 100 244

Level of education Treatment outcome TotalTS TF De

** and * indicate significance at 1% and 5% respectively.

42

These results suggest that there is a statistically significant relationship between treatment outcome

and level of education (p = 0.000). It is clear that among the educated people there is a higher

possibility to be a treatment success and less possibility be a defaulter. Education level does not have

considerable effect to be a treatment failure. The positive value of the standardized residual indicates

that the observed frequency of the cell is significantly above its expected frequency. Among the

patient’s who have the education level up to grade 5, number of reported patients is higher than

expected and also it is statistically significant. Among the patients’ who have higher education level

of up to A/L or above more likely to be a treatment success than be a defaulter.

Table 10: Analysis of the treatment outcome and level of education

Table 11. Relationship between marital status and treatment outcome.

Source: IHP TB survey 2009

There is no any effect to the treatment outcome whether the patent is married or not (chi-

square with two degree of freedom = 3.4388 , p = 0.179).

% Number % Number % Number % Number Married 81 115 92.9 26 75.7 56 80.7 197Unmarried 19 27 7.1 2 23 17 18.9 46Divorced 0 0 0 0 0 0 0 0Separated 0 0 0 0 1.4 1 0.4 1Widowed 0 0 0 0 0 0 0 0Total 100 142 100 28 100 74 100 244

Marital Status

Treatment outcomeTotalTS TF De

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

TS TF DeUp to grade 5 48 17 47

(-2.12*) (1.26) (2.15*)Up to grade 10 28 6 21

(-0.70) (-0.07) (1.00)Up to O/L 35 2 4

(2.29*) (-1.21) (-2.42*)Up to A/L and above 29 2 2

(2.25*) (-0.88) (-2.55*)Fisher's exact = 0.000

Level of education

Treatment outcome

43

Table 12: Analysis of the treatment outcome and marital status

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 Married patients get family support and more likely to interest to cure as it spread to others.

Since it is expected married people to be treatment success and unmarried patients to be

defaulters. Though we expect a relationship between marital status and treatment outcome,

the result suggests that there is no statistical relationship between treatment outcome and

marital status.

Table 13.Relationship between occupation and treatment outcome.

Source: IHP TB survey 2009

These results suggest that there is no statistically significant relationship between Treatment

outcome and occupation (p = 0.152).

In the sample majority of the patients were either unemployed (35.2%) or self employed

(25%). Among treatment successors 39.4% were unemployed, while among defaulters those

employed were 44.6%.

TS TF DeMarried 115 26 56

(-0.01) (0.69) (-0.41)Unmarried 27 2 17

(0.02) (-1.43) (0.86)Fisher's exact = 0.177

MaritalStatus

Treatment outcome

% Number % Number % Number % Number Unemployed 39.4 56 28.6 8 29.7 22 35.2 86Self employed 23.2 33 35.7 10 24.3 18 25 61Employed 32.4 46 32.1 9 44.6 33 36.1 88Retired 4.9 7 3.6 1 0 0 3.3 8Not respondend 0 0 0 0 1.4 1 0.4 1Total 100 142 100 28 100 74 100 244

TotalTreatment outcomeOccupation

TS TF De

44

Table 14. Relationship between nature of occupation and treatment outcome.

Source: IHP TB survey 2009

44.6% of the defaulters were unskilled labourers while there were only 18.3% and 14.3%

unskilled labourers among treatment successors and treatment failures respectively.

Table 15. Relationship between treatment outcome and being in prison.

Source: IHP TB survey 2009

Out of the patients who have ever been in prison 57.8% have defaulted the treatment regime.

While among the patients who have never been to prison 65.1% have successfully completed

the treatment regime. It is noted that 18.44% of the patients had been in prison one time or

other which is significant.

% Number % Number % Number % Number Technical and professional 6.3 9 3.6 1 4.1 3 5.3 13Administration and management 0.7 1 0 0 0 0 0.4 1

Trained officer 0.7 1 0 0 1.4 1 0.8 2

Clerical work 2.1 3 7.1 2 0 0 2 5

Teacher 1.4 2 0 0 0 0 0.8 2Agriculture and farming 1.4 2 14.3 4 2.7 2 3.3 8Unskilled labourer 18.3 26 14.3 4 44.6 33 25.8 63Others 23.9 34 28.6 8 17.6 13 22.5 55Not responded 45.1 64 32.1 9 29.7 22 38.9 95

Total 100 142 100 28 100 74 100 244

TotalTreatment outcome

Nature of occupation

TS TF De

% Number % Number % Number % NumbTS 31.1 14 65.1 127 25 1 58.2 1TF 11.1 5 11.8 23 0 0 11.5De 57.8 26 23.1 45 75 3 30.3Total 100 45 100 195 100 4 100 2

Treatment outcome

Ever been imprisoned

TotalYes No Not Responded

45

Table 16: Analysis of the treatment outcome and imprisonment

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results indicate that there is no statistically significant relationship between the

treatment outcome and imprisonment (chi-square with two degree of freedom = 22.098, p =

0.000). Imprisonment of tuberculosis patient causes him to be a defaulter. Most of the

imprison people come from lower level of the society. Being a prisoner has a significant

affect to the treatment outcome. Table 17.Relationship of smoking with treatment outcome.

Source: IHP TB survey 2009

Table 18. Relationship of alcohol use and treatment outcome

Source: IHP TB survey 2009 Table 19. Relationship of use of narcotic substances and treatment outcome

Source: IHP TB survey 2009

Note: This table takes into account only those patients who responded as narcotic substances

and others.

Yes NoTS 14 127

(-2.42*) (1.16)TF 5 23

(-0.11) (0.05)De 26 45

(3.48**) (-1.67)Pearson chi2(2) = 22.0984 Pr = 0.000

TreatmentOutcome

Ever been imprisoned

Smoking habits% Number % Number % Number % Number

Never smoked 45.1 64 39.3 11 21.6 16 37.3 91Smoked in the past & stopped completely 21.1 30 25 7 41.9 31 27.9 68Currently smoking 32.4 46 35.7 10 33.8 25 33.2 81Not Responded 1.4 2 0 0 2.7 2 1.6 4Total 100 142 100 28 100 74 100 244

TS TF De Total

% Number % Number % Number % NumberOccasionally 36.6 52 42.9 12 45.9 34 40.2 98Regularly 9.9 14 21.4 6 33.8 25 18.4 45Never 52.1 74 35.7 10 20.3 15 40.6 99Not Responded 1.4 2 0 0 0 0 0.8 2Total 100 142 100 28 100 74 100 244

TotalUse of alcohol

TS TF De

Use of narcotic substances% Number % Number % Number % Number

Heroin 100 4 0 0 66.7 2 75 6Other 0 0 100 1 33.3 1 25 2Total 100 4 100 1 100 3 100 8

TotalTS TF De

46

It is observed that majority of the patients had been smoking or were currently smoking

(61.1%).Even Alcohol use have been high with 58.6% reporting that they take alcohol

regularly or occasionally. Among patients who had completed treatment successfully 45.1%

had never smoked, 52.1% had never used alcohol and 4 people had used heroin. Among the

failures 35.7% were currently smoking and 21.4% were taking alcohol regularly. Among

defaulters 33.8% were currently smoking and 33.8% were regularly consuming alcohol.

Table 20: Analysis of the treatment outcome and smoking habits

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

These results suggest that there is a statistically significant relationship between treatment

outcome and smoking habit (p = 0.000). Most of the defaulters have smoked in the past and

stopped smoking completely. The never smoking TB patient is less likely to be a defaulter.

Table 21: Analysis of the treatment outcome and smoking habits

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results shows that there is a statistically significant relationship between treatment

outcome and smoking habit (p = 0.000).

Treatment success patients are not regularly smokers. The TB patient who never smokes is

likely to be a treatment success person. Among the defaulters there are more patients who

TS TF DeNever smoked 64 11 16

(1.50) (0.12) (-2.16*)Smoked in the past & stopped completely 30 7 31

(-1.53) (-0.33) (2.35*)Currently smoking 46 10 25

(-0.18) (0.18) (0.14)Pearson chi2(4) = 14.9948 Pr = 0.005

Smoking habits Treatment outcome

TS TF DeOccasionally 52 12 34

(-0.62) -0.2 -0.74Regularly 14 6 25

(-2.36*) -0.35 (3.03**)Never 74 10 15

(2.21*) (-0.43) (-2.78**)Pearson chi2(4) = 28.6089 Pr = 0.000

Smoking habitsTreatment outcome

47

are regularly smokers than never smoking. This indicates that smoking habits have an effect

to the treatment outcome.

Table 22. Relationship between monthly income and treatment outcome.

Source: IHP TB survey 2009 31.6% of the sample was without a regular income. Large numbers of patients in all treatment

outcome categories were without regular income. i.e 28.9%, 32.1%and 36.5% in the

treatment successors, failures and defaulters categories respectively were with out any

income. Table 23. Relationship between patients’ understanding about the disease and treatment outcome.

Source: IHP TB survey 2009

85.9% of the treatment successors and 89.3% of the treatment failures have perceived that

they have a good understanding about the disease. But it was only 50% among the defaulters

who thought that they had a good understanding of the disease.

Table 24: Analysis of the treatment outcome and patient’s understanding about the disease

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

% Number % Number % Number % NumberNo regular income 28.9 41 32.1 9 36.5 27 31.6 77<3,500 8.5 12 3.6 1 9.5 7 8.2 203.501 – 7,500 13.4 19 25 7 25.7 19 18.4 457,501 – 12,000 15.5 22 14.3 4 6.8 5 12.7 3112,001 – 20,000 19 27 17.9 5 12.2 9 16.8 41>20,000 3.5 5 0 0 0 0 2 5Does not like to disclose 11.3 16 7.1 2 9.5 7 10.2 25Total 100 142 100 28 100 74 100 244

TotalMonthly income(Rs) TS TF De

% Number % Number % Number % NumberYes 85.9 122 89.3 25 50 37 75.4 184No 14.1 20 10.7 3 48.6 36 24.2 59Not Responded 0 0 0 1.4 1 0.4 1

100 142 100 28 100 74 100 244 Total

Have a good understanding

Patient's perception TS TF De Total

TS TF DeYes 122 25 37

(1.40) (0.82) (-2.46*)No 20 3 36

(-2.47*) (-1.46) (4.34**)Fisher's exact = 0.000

Patient's perception Treatment Outcome

Patient perceived as having a good understanding about the disease

48

These results suggest that there is a statistically significant relationship between treatment

outcome and patient’s understanding about the disease (p = 0.000). It is clear that those who

have good understanding about the disease more likely to be a treatment success. There is a

possibility to be a defaulter among those who do not have a good understanding about the

disease. The factor of the understanding about the disease does not have any effect on the

treatment failures. Table 25. Relationship between mode of acquiring information and treatment outcome.

Source: IHP TB survey 2009 Note : Totals do not add up to sample size due to multiple responses to the question

Most of the patients had received information and education regarding TB through

government health personal mainly by MO’s and Nurses at chest clinics and at DOT centers.

Among patients who had completed treatment successfully, 46% of them were educated at a

chest clinic by Medical Officers. Among treatment failures 7.1% had acquired information

from other patients while only 9.5% had referred health leaflets for acquiring information.

But it is to be noted that out of the defaulters 65.4% had been educated at a chest clinic by

Medical Officers.

It appears that mass communication and other health educational material has not played a

major role in information transfer.

% Number % Number % Number % NumberEducation by MOs at chest clinic 46 81 41 17 65.4 34 48.7 132Education by Nurses at chest clinic/DOT center 32 56 26 11 19.2 10 28.4 77Education by other health care personnel 14 25 17 7 11.5 6 14 38From other patients 1.1 2 7.1 3 1.9 1 2.2 6Health leaflets 7.3 13 9.5 4 1.9 1 6.6 18Internet 0 0 0 0 0 0 0 0Mass media 0 0 0 0 0 0 0 0

Mode Treatment outcome TotalTS TF De

49

Table 26. Relationship of impact of having TB on the occupation and to the treatment outcome

Source: IHP TB survey 2009

32% of the patients were unable to attend work daily. Out of the defaulters 44.6% have

mentioned that they were unable to attend work daily. 39.3% of the treatment failures also

have mentioned the same while it was only 23.9% among the treatment successors.

Table 27: Analysis of the treatment outcome and affect to the work

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

These results suggest that there is a statistically significant relationship between treatment

outcome and impact to the work (p = 0.000). However Results need to be interpreted

cautiously since those who are not employed will not have any impact to their work. Table 28 . The distance to the DOT center in relation to the treatment outcome

Source: IHP TB survey 2009

% Number % Number % Number % NumberNo impact 67.6 96 53.6 15 50 37 60.7 148Unable to attend work daily 23.9 34 39.3 11 44.6 33 32 78Transferred to a different work placeKept off work during treatment 2.8 4 3.6 1 0 0 2 5Dismissed from the job 0 0 0 0 1.4 1 0.4 1Others 2.8 4 3.6 1 2.7 2 2.9 7Not Responded 2.1 3 0 0 1.4 1 1.6 4Total 100 142 100 28 100 74 100 244

0.4 10.7 1 0 0 0 0

ImpactTotal

Treatment OutcomeTS TF De

TS TF DeNo impact 96 15 37

(1.11) (-0.55) (-1.19)

34 11 33

(-1.66) (0.63) (1.90)

Other 9 2 3

(0.31) (0.29) (-0.61)

Fisher's exact = 0.028

Impact

Treatment Outcome

Unable to attend work daily

% Number % Number % Number % Number % NumberTS 58.1 111 60 21 33.3 1 60 9 58.2 142TF 13.1 25 5.7 2 0 0 6.7 1 11.5 28De 28.8 55 34.3 12 66.7 2 33.3 5 30.3 74Total 100 191 100 35 100 3 100 15 100 244

Outcome DistanceTotal<5km 5-20km >20km Not Responded

50

Only 1.23% of the patients had to travel >20kms to attend the DOT center. 78.3% had less

than 5kms to travel. Out of those who had less than 5kms to travel 28.8% were defaulters.

18.9% of the defaulters had to travel >5kms.

Table 29 . The place where the patient had to go for DOT and the distance to the DOT center (All patients)

Source: IHP TB study 2009 15.57% of the patients had to travel >5kms to attend the chest clinics, government hospitals or the CDs for DOT.

% Number % Number % Number % Number % NumberThe chest clinic 17.8 34 25.7 9 33.3 1 6.7 1 18.4 45

Government hospital 30.4 58 57.1 20 66.7 2 26.7 4 34.4 84

Central dispensary 29.8 57 17.1 6 0 0 0 0 25.8 63

PHM /PHN 9.9 19 0 0 0 0 6.7 1 8.2 20

GP 1.6 3 0 0 0 0 0 0 1.2 3

Work place 0 0 0 0 0 0 0 0 0 0

Family member at home 1.6 3 0 0 0 0 20 3 2.5 6

With community volunteer 3.1 6 0 0 0 0 0 0 2.5 6

Other 3.7 7 0 0 0 0 40 6 5.3 13Not responded 2.1 4 0 0 0 0 0 0 1.6 4Total 100 191 100 35 100 3 100 15 100 244

TotalPlace where they have to go

for DOTDistance

<5km 5-20km >20km Not Respond

51

Table 30. Effect of the monthly income and the expenditure for each visit to the DOT center on the treatment outcome

Source: IHP TB survey 2009

39.75% 0f the patients did not have to spend money to visit the DOT center daily. 15.6% of the patients who had to spend more than 20 rupees

for each visit had no regular income.

Table 31. Relationship of the loss of income after the diagnosis of TB and the expenditure for each visit to the DOT center with the treatment outcome

Source: IHP TB survey 2009

46.7% of the patients have lost their income after the diagnosis of TB. Out of them 20.2% had to spend more than Rs. 20 for each visit to the

DOT center.

% Number % Number % Number % Number % Number % Number % Number % Number % Number % Number % Number % Number % Number33.3 18 40.0 6 25.0 7 32.4 12 14.3 1 26.7 4 21.4 9 25.0 1 33.3 2 22.2 2 50.0 1 33.3 2 31.6 7711.1 6 6.7 1 14.3 4 2.7 1 0.0 0 6.7 1 7.1 3 0.0 0 0.0 0 22.2 2 0.0 0 0.0 0 8.2 2018.5 10 26.7 4 28.6 8 13.5 5 28.6 2 53.3 8 7.1 3 25.0 1 16.7 1 11.1 1 0.0 0 16.7 1 18.4 4516.7 9 13.3 2 7.1 2 16.2 6 14.3 1 6.7 1 16.7 7 25.0 1 0.0 0 0.0 0 0.0 0 0.0 0 12.7 3111.1 6 13.3 2 14.3 4 16.2 6 28.6 2 6.7 1 33.3 14 25.0 1 33.2 2 11.1 1 0.0 0 33.3 2 16,8 411.9 1 0.0 0 0.0 0 8.1 3 0.0 0 0.0 0 2.4 1 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 2.0 57.4 4 0.0 0 10.7 3 10.8 4 14.3 1 0.0 0 11.9 5 0.0 0 16.7 1 33.3 3 50.0 1 16.7 1 10.2 25

100.0 54 100.0 15 100.0 28 100.0 37 100.0 7 100.0 15 100.0 42 100.0 4 100.0 6 100.0 9 100.0 2 100.0 6 100.0 244

Monthly income

(Rs) TS TF

Expenditure in rupeesTotal

12,001 – >20,000Does not like

No regular <3,5003.501 – 7,5007,501 –

De>20

Defaulter TS TF De DeNot Responded

Total

Nil <20TS TFTS TF

% Number % Number % Number % Number % Number % Number % Number % Number % Number % Number % Number % Number%

Number

Yes 46.3 25 53.3 8 50.0 14 43.2 16 57.1 4 53.3 8 40.5 17 50.0 2 66.7 4 11.1 1 50.0 1 66.7 4 46.7 114

No 35.2 19 33.3 5 32.1 9 27.0 10 14.3 1 20.0 3 35.7 15 50.0 2 16.7 1 44.4 4 0.0 0 16.7 1 31.1 76NotResponded

18.5 10 13.3 2 17.9 5 29.7 11 28.6 2 26.7 4 23.8 10 0.0 0 16.7 1 44.4 4 50.0 1 16.7 1 22.1 54

Total 100.0 54 100.0 15 100.0 28 100.0 37 100.0 7 100.0 15 100.0 42 100.0 4 100.0 6 100.0 9 100.0 2 100.0 6 100.0 244

Loss of income after

the diagnosis of

TBTS TF

Expenditure in rupees

Total

De

>20

Defaulter TS TF De De

Not RespondedNil <20

TS TFTS TF

52

Table 32. Relationship of the treatment outcome to the time spent for each visit to the DOT center

Source: IHP TB survey 2009 Only 8.6% of patients had to spend more than 1 hr for each visit to the DOT center.13.5% of the

defaulters and 7.0% of the treatment successors had spend more than I hour. 50.8% of the

patients had spent less than 15 mins. 68.9% of the defaulters had spent less than 30 mins for each

visit.. 65.8% of those who had to spend 15 – 30 mins were in the treatment successors group

while 21.9% were defaulters.

Table 33: Analysis of the treatment outcome and time spend of each visit

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

These results suggest that there is a no any statistically significant relationship between treatment

outcome and time spent for each visit (p = 0.085) at 1% and 5% significant level.

% Number % Number % Number % Number % Number % NumberTS 58.1 72 65.8 48 46.2 12 50 2 47.1 8 58.2 142TF 13.7 17 12.3 9 3.8 1 0 5.9 1 11.5 28De 28.2 35 21.9 16 50 13 50 2 47.1 8 30.3 74Total 100 124 100 73 100 26 100 4 100 17 100 244

Treatment outcome

Time spent for each visit Total<15 mins 15-30 mins 30 mins – 1 hr. 1 – 2 hrs. >2 hrs

<15 mins 15-30 mins 30 mins – 1 hr. >1 hrs.TS 72 48 12 10

(-0.02) (0.85) (-0.80) (-0.64)TF 17 9 1 1

(0.73) (0.22) (-1.15) (-0.91)Defaulters 35 16 13 10

(-0.43) (-1.30) (1.82) (1.44)Fisher's exact = 0.085

Treatmentoutcome

Time spent for each visit

53

Table 34. Relationship of mode of transport to the DOT center and the treatment outcome.

Source: IHP TB survey 2009

35.7% of the patients had used public transport while 34% had walked to the DOT center. 3.7%

had used a hired vehicle. 42.9% the treatment failures and 35.1% of the defaulters had walked to

the DOT center. Table 35. Relationship of the place where they had to go for DOT with the treatment outcome and daily intake of drugs.

Source: IHP TB survey 2009

93.6% of treatment successors and 93% of the treatment failures have taken drugs daily.

% Number % Number % Number % NumberWalking 31.7 45 42.9 12 35.1 26 34 83Private vehicle 21.8 31 28.6 8 12.2 9 19.7 48Public transport 36.6 52 21.4 6 39.2 29 35.7 87Hired vehicle 4.2 6 0 0 4.1 3 3.7 9Not Responded 5.6 8 7.1 2 9.5 7 7 17Total 100 142 100 28 100 74 100 244

TotalMode of Transport

TS TF De

% Number % Number % Number % Number % Number % Number The chest clinic 20.3 27 11.5 3 37.5 3 0 0 0 0 19.4 33Government hospital 33.1 44 42.3 11 37.5 3 100 1 50 1 35.3 60Central dispensary 23.3 31 19.2 5 0 0 0 0 0 0 21.2 36PHM /PHN 8.3 11 11.5 3 12.5 1 0 0 50 1 9.4 16GP 0.8 1 0 0 0 0 0 0 0 0 0.6 1Work place 0 0 0 0 0 0 0 0 0 0 0 0Family member at home 3.8 5 0 0 0 0 0 0 0 0 2.9 5With community 2.3 3 0 0 0 0 0 0 0 0 1.8 3Other 5.3 7 15.4 4 12.5 1 0 0 0 0 7.1 12Not Responded 3 4 0 0 0 0 0 0 0 0 2.4 4Total 100 133 100 26 100 8 100 1 100 2 100 170

Not Responded TotalPlace where they have

to go for DOTDid take drugs daily Did not take drugs daily

TS TF TS TF

54

Table 36: Analysis of the treatment outcome and where they go for DOT

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results suggest that there is a no statistically significant relationship between treatment

outcome to be a treatment successors or treatment failure and time spent for each visit (p =

0.711). Table 37. Relationship of Defaulters’ travel expenditure to the DOT center with the place where they have to go for DOT.

Source: IHP TB survey 2009

4% of the defaulters had attended the chest clinics, govt. hospitals or CDs for DOT spending

more than Rs. 60 for each visit. 82.1% of the defaulters who did not spend money to visit the

DOT center had DOT at places other than the chest clinics or the govt. hospitals.

TS TFThe chest clinic 27 3

(0.41) (-0.91)Government hospital 44 11

(-0.26) (0.58)Central dispensary 31 5

(0.19) (-0.42)PHM /PHN 11 3

(-0.19) (0.43)Other 16 4

(-0.16) (0.35)

Fisher's exact = 0.711

Place where they have to go for DOT

Did take drugs daily

% Number % Number % Number % Number % Number % Number The chest clinic 20.3 27 11.5 3 37.5 3 0 0 0 0 19.4 33Government hospital 33.1 44 42.3 11 37.5 3 100 1 50 1 35.3 60Central dispensary 23.3 31 19.2 5 0 0 0 0 0 0 21.2 36PHM /PHN 8.3 11 11.5 3 12.5 1 0 0 50 1 9.4 16GP 0.8 1 0 0 0 0 0 0 0 0 0.6 1Work place 0 0 0 0 0 0 0 0 0 0 0 0Family member at home 3.8 5 0 0 0 0 0 0 0 0 2.9 5With community 2.3 3 0 0 0 0 0 0 0 0 1.8 3Other 5.3 7 15.4 4 12.5 1 0 0 0 0 7.1 12Not Responded 3 4 0 0 0 0 0 0 0 0 2.4 4Total 100 133 100 26 100 8 100 1 100 2 100 170

Not Responded TotalPlace where they have

to go for DOTDid take drugs daily Did not take drugs daily

TS TF TS TF

55

Table 38. Relationship of the patient’s perceived need to attend at a specific time of a day to the DOT center on the treatment outcome

Source: IHP TB survey 2009

78.2% of the treatment successors had mentioned that attending the DOT center at a specific

time of the day was possible always but only 52% of the TFs and defaulters had said that it was

possible always. Only 2.8% of the treatment successors and 3.9% of the TFs & defaulters have

mentioned that it was impossible to attend the DOT center at a specific time. 27.5% of the TFs &

defaulters had mentioned that it is possible mostly.

Table 39. Relationship of the treatment outcome of those who found it difficult / impossible to attend the DOT center at a specific time with the place where they have to go for DOT.

Source: IHP TB survey 2009

Note: Totals do no add up to sample size due to the response being determined by previous

answer(Table 22).

Most of those who have said that it is difficult / impossible to attend the DOT center at a specific

time of the day had to attend chest clinics, Government hospitals and central dispensaries for

DOT. One person found it difficult to attend at a specific time of the day to the DOT center of

the community volunteer.

% Number % NumberPossible always 78.2 111 52 53Possible mostly 12 17 27.5 28Difficult 1.4 2 8.8 9Impossible 2.8 4 3.9 4Not Responded 5.6 8 7.8 8Total 100 142 100 102

Feasibility of attendingTS TF & De

% Number % Number % Number % Number % Number % NumberThe chest clinic 0 0 50 2 0 0 0 0 12.5 1 0 0Government hospital 0 0 25 1 0 0 0 0 37.5 3 25 1Central dispensary 50 1 0 0 0 0 0 0 50 4 50 2PHM /PHN 0 0 0 0 100 1 0 0 0 0 0 0GP 0 0 0 0 0 0 0 0 0 0 0 0Work place 0 0 0 0 0 0 0 0 0 0 0 0Family member at home 0 0 0 0 0 0 0 0 0 0 0 0With community volunteer 0 0 0 0 0 0 0 0 0 0 25 1Other 50 1 25 1 0 0 0 0 0 0 0 0

Place where they have to go for DOT

TS TF DeDifficult Impossible Difficult Impossible Difficult Impossible

56

Table 40. The treatment outcome in relation to whether they swallowed the tablets daily in front of the DOT provider at the time of visiting the DOT center

Source: IHP TB survey 2009 75.4% of the patients had swallowed the tablets in front of the DOT provider.

Table 41. The place of the DOT center of those who did not swallow the tablets daily in front of the DOT provider at the time of visiting.

Source: IHP TB survey 2009

70.9% of those who did not swallow the tablets in front of the DOT providers had attended

government health institutes. It is also noted that 10.9% of those who did not swallow the tablets

in front of the DOT providers had family members or community volunteers as DOT providers.

% N % N % N % NTS 73.2 104 25.4 36 1.4 2 100 142TF 78.6 22 14.3 4 7.1 2 100 28De 78.4 58 20.3 15 1.4 1 100 74

Treatment outcome

TotalYes No Not Responded

Swallowed the tablets daily in front of the DOT provider at the time of visiting the DOT center

% NumberThe chest clinic 20 11Government hospital 29.1 16Central dispensary 21.8 12PHM /PHN 7.3 4GP 1.8 1Work place 0 0Family member at home 3.6 2With community volunteer 7.3 4Other 7.3 4Not Responded 1.8 1Total 100 55

Place of the DOT center Did not swallow the tablets daily in front of the DOT provider at the time of

visiting

57

Table 42.Treatment outcome in relation to frequency of DOT

Source: IHP TB survey 2009 There are no treatment failures and defaulters among those who had weekly DOT through out

the course of treatment. Defaulters are higher in comparison to the treatment successors and

failures in category ‘other in IP and CP’.

Table 43. Point of default after initiation of treatment in relation to the frequency of DOT

Source: IHP TB survey 2009 52.7% of the defaulters had discontinued treatment between 2 – 4 months while 18.9% and

17.56% had discontinued between 1 – 2 months and 4 -6 months respectively. Most of the

defaulters are those who had daily DOT in IP and weekly / other in CP and had defaulted in the

CP (59.5%).

Frequency of DOT% Number % Number % Number %

Daily DOT in IP + CP 3.5 5 17.9 5 2.7 2Daily DOT in IP &

22.5 32 28.6 8 13.5 10 2

Weekly in IP + CP 1.4 2 0 0 0 0Daily DOT in IP & other

53.5 76 42.9 12 59.5 44 5

Other in IP + CP 19 27 10.7 3 24.3 18Total 100 142 100 28 100 74

TS TF De

% Number % Number % Number % Number % Number % NumberDaily DOT in IP + CP 0 0 0 0 5.1 2 0 0 0 0 2.7 2Daily DOT in IP & Weekly DOT in CP 0 0 7.1 1 17.9 7 15.4 2 0 0 13.5 10Weekly in IP + CP 0 0 0 0 0 0 0 0 0 0 0 0Daily DOT in IP & other in CP 63.6 7 78.6 11 46.2 18 61.5 8 0 0 59.5 44Other in IP + CP 36.4 4 14.3 2 20.5 8 15.4 2 100 2 24.3 18Total 100 11 100 14 100 39 100 13 100 2 100 74

Frequency of DOT point of default after initiation of treatment

<1 month1 – 2

months2 - 4

months4 – 6

months Not Responded Total

58

Table 44. Reasons given by patients for non daily DOT during the course of treatment (IP / CP / IP + CP)

Reason for Non daily DOT TS TF De Total DOT provider requested to take drugs at home

11 2 5 18

Patient requested to take drugs at home 55 4 17 76 After the IP requested to come once a week

89 20 37 146

Source: IHP TB survey 2009 Note : Totals does not add up to sample size as the numbers on ‘daily DOT’ has been excluded

Table 45. Reasons for the patient to request the drugs to be taken home among those with different treatment outcomes

Source: IHP TB survey 2009

Note: Totals do not add up due to multiple responses to the question

Commonest reason for requesting drugs to be taken home was that they felt it was easy.

Difficulty in travelling daily and the nature of the occupation were some other reasons

mentioned.Out of the treatment successors 40.9% thought it was easier to take drugs at home

while the same percentage preferred to take drugs at home due to difficulties in daily travelling.

In the treatment failure group the main reasons given as requesting to take drugs at home were

the following. Due to nature of the occupation (40%), it was easy (40%), and difficulties in daily

travelling (40%).

% Number % Number % Number % NumberIt was easy 40.9 18 40 2 54.5 6 43.3 26Nature of occupation 27.3 12 40 2 45.5 5 31.7 19Daily travelling was difficult 40.9 18 40 2 81.8 9 48.3 29Travelling was costly 4.5 2 0 0 18.2 2 6.7 4Difficulty in transport 13.6 6 0 0 54.5 6 20 12As there was no one to go with him 0 0 0 0 18.2 2 3.3 2Needed to maintain privacy 9.1 4 0 0 0 0 6.7 4Due to problems at the treatment place 2.3 1 0 0 0 0 1.7 1Poor reception at the treatment center 0 0 0 0 0 0 0 0Fearing social stigma 9.1 4 0 0 0 0 6.7 4Other 6.8 3 20 1 0 0 6.7 4Total 100 44 100 5 100 11 100 60

Reasons for the patient to request the drugs to be taken home TS TF De Total

59

Table 46 .The views of the patients regarding the need to visit DOT center daily for treatment with different treatment outcomes.

Source: IHP TB survey 2009 52.8% of the treatment successors, 57.1% of the TFs and 25.7% of the defaulters have said that

the need to visit a DOT center daily for treatment was very good and acceptable. 29.6% of the

TSs and 35.7% of TFs have said that it was good but not always. 32.4% of the defaulters have

said that it was troublesome as it interfered with daily activities and 5.4% have said that it was an

important reason for defaulting. Table 47. Reasons for defaulting as stated by the defaulters who have said that the need to visit DOT center daily for treatment is very good and acceptable & good but not always

Source: IHP TB survey 2009 Note : Totals do not add up due to multiple responses to the question

Most of the defaulters who have said that the need to visit DOT center daily for treatment is very

good and acceptable & good but not always, have stopped treatment on their own because they

have felt better. The other common reasons were income problems, occupational problems and

the poor family support.

% Number % Number % Number % NumberVery good and acceptable 52.8 75 57.1 16 25.7 19 45.1 110Good but not always 29.6 42 35.7 10 25.7 19 29.1 71Troublesome but does not interfere with daily activities 2.8 4 3.6 1 1.4 1 2.5 6Troublesome as it interferes with daily activities 8.5 12 3.6 1 32.4 24 15.2 37Waste of time 2.1 3 0 0 1.4 1 1.6 4Important reason for defaulting 0 0 0 0 5.4 4 1.6 4Not Responded 4.2 6 0 0 8.1 6 4.9 12Total 100 142 100 28 100 74 100 244

Treatment outcome Patients’ view TS TF De Total

Treatment outcome Patients’ viewVery good and acceptable & Good but not always

Distance to DOT center 5Income Problems 13Occupational problems 9Stigma 1Poor family support 8Stopped on own because felt better 17Decided to go to other place 2Attitudes & practices of staff at Dot centre 2Lack of proper awareness about the treatment 3other 13

Reasons for defaulting

60

Table 48. Relationship of the awareness & the development of side effects to the treatment outcome

Source: IHP TB survey 2009

62.7% of the patients were aware of the side effects of the drugs. But 54.1% of the defaulters

were not aware of the side effects. Only 20.5% of the patients had developed side effects during

treatment. 42.9% of the treatment failures have developed side effects while only 18.3% and

16.2% of the TSs and defaulters respectively had developed side effects.

Table 49: Analysis of the treatment outcome and awareness of side effects

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

Table 50: Analysis of the treatment outcome and development of side effects

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

% Number % Number % Number % NumberYes 69 98 75 21 45.9 34 62.7 153No 31 44 25 7 54.1 40 37.3 91Yes 18.3 26 42.9 12 16.2 12 20.5 50No 81 115 57.1 16 82.4 61 78.7 192

Not Responded 0.7 1 0 1.4 1 0.8 2

Total 100 142 100 28 100 74 100 244

Awareness of side effects

Development of side effects

Awareness & development of side effectsTreatment outcome

TS TS De Total

TS TF DeYes 98 21 34

(0.95) (0.82) (-1.82)No 44 7 40

(-1.23) (-1.07) (2.36*)Pearson chi2(2) = 13.1143 Pr = 0.001

Awareness ofside effects

Treatment Outcome

TS TF DeYes 26 12 12

(-0.58) (2.58*) (-0.79)No 115 16 61

(0.30) (-1.32) (0.41)Pearson chi2(2) = 9.6338 Pr = 0.008

Development ofside effects

Treatment Outcome

61

These results suggest that there is a statistically significant relationship between treatment

outcome and development of side effects (p = 0.000). Those who have developed side effects are

likely to be a treatment failure. As we notice most of the other factors do not have significant

effect to treatment failure category.

Table 51. Relationship of the response to the side effects of the patients who had developed side effects to treatment.

Source: IHP TB survey 2009 86% of the patients who developed side effects have sought medical advice while continuing

treatment. 52% of those who developed side effects were in the treatments success group while

24% were in the treatment failure group. 8% have discontinued treatment and stayed at home.

One patient out of that has been successfully treated later. Table 52. Relationship of stigma to the treatment outcome

Source: IHP TB survey 2009

Only 9% of the patients have been stigmatized as a TB patient in public. Of those who had been

stigmatized most of them have been stigmatized by a family member.

% Number % Number % Number % NumberIgnored & continued treatment 3.8 1 0 0 16.7 2 6 3Sought medical advice while continuing treatment 92.3 24 100 12 58.3 7 86 43Discontinued treatment & sought medical advice 0 0 0 0 0 0 0 0Discontinued treatment & stayed at home 3.8 1 0 0 25 3 8 4Other 0 0 0 0 0 0 0 0Not Responded and Not applicable 0 0 0 0 0 0 0 0Total 100 26 100 12 100 12 100 50

Patients’ response to the side effects

TS TF De Total

% Number % Number % Number % NumberYes 7 10 10.7 3 20.3 15 11.5 28No 93 132 89.3 25 79.7 59 88.5 216

0 0 0 0 73.3 11 39.3 1120 2 33.3 1 40 6 32.1 940 4 0 0 0 0 14.3 430 3 66.7 2 26.7 4 32.1 910 1 0 0 0 0 3.6 110 1 0 0 0 0 3.6 1

Situation TS TF De Total

Stigmatized as a TB patient in public

Stigmatization by Family memberRelativeColleague at work VillagersPerson at the

Other

62

Table 53. Perception on DOT of the patients with different treatment outcomes

Source: IHP TB survey 2009 21.6% of the defaulters and 32.1% of the TFs have perceived that DOT was necessary for all

patients. 73% of the defaulters and 64.1% of the treatment successors had said that they do not

need an observer to take care of themselves. There were 70.6% of the patients felt that they could

have continued medicines without any interruption even without a supervisor. Table 54. Treatment outcome in relation to the family support to the patient

Source: IHP TB survey 2009

67.6% of the patients in the sample had been living with the spouse and 16% with other relatives.

6.6% have been living alone and 75% out of them have defaulted. 73.2% of the treatment

successors and 78.6% of the treatment failures were living with the spouse. Out of those who

were living with the spouse only 23.6% have defaulted.

% Number % Number % Number % NumberYes 54.22535 77 64.28571 18 43.24324 32 52.04918 127No 45.07042 64 32.14286 9 54.05405 40 46.31148 113Not Responded 0.704225 1 3.571429 1 2.702703 2 1.639344 4Total 100 142 100 28 100 74 100 244Yes 35.2 50 60.7 17 24.3 18 34.8 85No 64.1 91 35.7 10 73 54 63.5 155Not Responded 0.7 1 3.6 1 2.7 2 1.6 4Total 100 142 100 28 100 74 100 244Yes 70.4 100 71.4 20 70.6 120No 27.5 39 25 7 27.1 46Not Responded 2.1 3 3.6 1 2.4 4Total 100 142 100 28 100 170

Necessary for all patients

Need an observer / supervisor to take care of himself

Would have continued medicines without any interruption even without a supervisor

Perception on DOT Treatment outcomeTS TF De Total

% Number % Number % Number % Number1.4 2 7.1 2 16.2 12 6.6 16

Spouse 73.2 104 78.6 22 52.7 39 67.6 165Married child 4.2 6 3.6 1 1.4 1 3.3 8Other relative 12 17 7.1 2 27 20 16 39Friends 0 0 0 0 0 0 0 0Other 9.2 13 3.6 1 2.7 2 6.6 16

100 142 100 28 100 74 100 244

Total

Patients living alonePatients living with

Total

Family support TS TF De

63

Table 55: Analysis of the treatment outcome and with whom patient living with

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results suggest that there is a statistically significant relationship between treatment

outcome and with whom patient living with (p = 0.000). Patients who live alone are more likely

to default. Table 56.Awareness of the family members that the patient was suffering from TB in relation to the treatment outcome

Source: IHP TB survey 2009

93.9% of the patients have stated that the family members were aware that they were suffering

from TB. 10.7% of the treatment failures and 12.2% of the defaulters have said that the family

members were not aware while in the treatment successors it was 1.4%.

TS TF DeAlone 2 2 12

(-2.40*) (0.12) (3.24**)Spouse 104 22 39

(0.81) (0.70) (-1.56)Married child 6 1 1

(0.62) (0.09) (-0.92)Relatives 17 2 20

(-1.20) (-1.17) (2.38*)Other 13 1 2

(1.21) (-0.62) (-1.29)Fisher's exact = 0.000

Treatment OutcomeParients living with

% Number % Number % Number % NumberYes 97.9 139 89.3 25 87.8 65 93.9 229No 1.4 2 10.7 3 12.2 9 5.7 14

Not Responded 0.7 1 NA 0 0 0 0.4 1

Total 100 142 100 28 100 74 100 244

Awareness of the family

TS TF De Total

64

Table 57: Analysis of the treatment outcome and awareness of the family

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

These results suggest that there is a statistically significant relationship between treatment

outcome and awareness of the family about the disease (p = 0.001). Most of the family members

of the treatment success group knew about the patient disease while among the defaulters, family

members did not know about the disease of the TB patient. This indicates that awareness of the

disease among family members may prevent defaulting.

Table 58. Patient perception regarding the family support in relation to the treatment outcome

Source: IHP TB survey 2009 73.9% of the treatment successors and 67.9% of the treatment failures have said that the family

support was excellent while it was only 20.3% among the defaulters. None of the treatment

successors or treatment failures had said that the family support was poor but 17.6% of the

defaulters have said that it was poor.

TS TF DeYes 139 25 65

(0.53) (-0.27) (-0.57)No 2 3 9

(-2.15*) (1.09) (2.29*)Fisher's exact = 0.001

Treatment OutcomeAwareness ofthe family

% Number % Number % Number % NumberExcellent 73.9 105 67.9 19 20.3 15 57 139Good 20.4 29 21.4 6 37.8 28 25.8 63Satisfactory 4.9 7 10.7 3 20.3 15 10.2 25Poor 0 0 0 0 17.6 13 5.3 13Indifferent 0 0 0 0 4.1 3 1.2 3

Not Responded 0.7 1 0 0 0 0 0.4 1

Total 100 142 100 28 100 74 100 244

Family support

TS TF De Total

65

Table 59: Analysis of the treatment outcome and family support

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results suggest that there is a statistically significant relationship between treatment

outcome and family support (p = 0.000). Most of the families of patients from the treatment

success category feel that the support of the family is excellent. As well as defaulters feel that

their family support is poor. Table 60. Reasons given by defaulters for not completing the whole regimen of treatment

Source: IHP TB survey 2009 * Note : Totals do not add up to sample size due to multiple responses to the question

TS TF DeExcellent 105 19 15

(2.71**) (0.75) (-4.20**)Good 29 6 28

(-1.25) (-0.47) (2.01*)Satisfactory 7 3 15

(-1.97*) (0.07) (2.68**)Poor 0 0 13

(-2.75**) (-1.22) (4.54**)Indifferent 0 0 3

(-1.32) (-0.59) (2.18*)Fisher's exact = 0.000

Treatment OutcomeFamilysupport

% NumberDistance to DOT center 17.6 13Income problems 33.8 25Occupational problems 27 20Stigma 1.4 1Poor family support 16.2 12Stopped on own because felt better 45.9 34Because I felt that I’m being wrongly diagnosed as TB and treated 9.5 7Decided to take treatment from somewhere else 2.7 2Side effects are intolerable 1.4 1Attitude and practices by health staff at DOT center 4.1 3Attitude and practices by health staff at other place (Specify) 1.4 1Others ( Specify) 20.3 15

FrequencyReason Given by Defaulters

66

“Stopped on own because felt better” was the most common reason given by most of the

defaulters for not completing the whole regimen. The other important reasons given were

“income problems”, “occupational problems” and “poor family support”.

Table 61. Reasons for seeking treatment again (for Cat 2) after defaulting

Source: IHP TB survey 2009 Note : Totals do not add up to sample size due to multiple responses to the question

The most common reason for seeking treatment again after defaulting was the “reappearance of

symptoms”. The next was the “persuasion by the PHI”.

Table 62 . Patients’ views with regard to the prevention of defaulting of treatment

Source: IHP TB survey 2009

Note : Totals do not add up to sample size due to multiple responses to the question

Most of the patients who had defaulted were of the view that “drugs to be provided to the

patient” would have prevented defaulting. The next view for prevention of defaulting was that

“DOT at home”.

% NReappearance of symptoms 33.8 25

PHI 27 20Any other health personnel 0 0Relative and friends 2.7 2Chest clinic 4.1 3DOT provider 0 0Community leaders 0 0Work place staff 0 0On own 0 0Legally 0 0

Other 0 0

Reason Frequency

Persuasion by

Patients’ views with regard to preventing default

% NumberDot at home 27 20Drugs to be provided to the patient 37.8 28Hospitalization 16.2 12DOT at the nearest health institution 4.1 3Dot by community providers 1.4 1No views 29.7 22

67

Table 63. Patients’ perception regarding the need of visiting the chest clinic regularly in relation to the treatment outcome

Source: IHP TB survey 2009 68.4% of the patients felt that regular chest clinic visits were not necessary. Out of 29.5% of

those who felt that regular chest clinic visits were necessary 69.4% were treatment successors.

But 62.7% of the treatment successors, 71.4% of the treatment failures and 79.7% of the

defaulters felt that it was not necessary to visit the chest clinic regularly.

Table 64. Reasons given why regular chest clinic visits are necessary

Source: IHP TB survey 2009 Note : Totals do not add up due to multiple responses to the question

The reason given by most of the patients who have said that regular chest clinic visits were

necessary was for investigations and sputum microscopy.

Treatment outcome

% Number % Number % Number % NumberTS 69.4 50 53 89 75 3 58.2 142TF 9.7 7 11.9 20 25 1 11.5 28De 20.8 15 35.1 59 0 0 30.3 74Total 100 72 100 168 100 4 100 244

Regular chest clinic visits necessary

Regular chest clinic visits not necessary

Not RespondedTotal

% Number % NumberFor investigations 35.41 17 33.3 4To get advices and 31.25 15 41.7 5Good patient care 14.5 7 0 0Closeness 4.16 2 8.3 1Other 14.58 7 16.7 2Total 100 48 100 12

Cause FrequencyTS & TF De

68

Table 65. Reasons given why regular chest clinic visits are not necessary.

Source: IHP TB survey 2009

Note : Totals do not add up due to multiple responses to the question The reason given by most of the patients who have said that regular chest clinic visits were not

necessary was the long distance they had to travel to the chest clinic. Among ‘other’ it is noted

that most of the patient feel that chest clinic visits are necessary when needed but not regularly. Table 66 .Patients’ suggestions to improve compliance.

Source: IHP TB survey 2009

Note : Totals do not add up to sample size due to multiple responses to the question

34.5% of the patients has suggested distributing the drugs closer to the home for improving

compliance Most of the treatment successors and treatment failures were of this view, while

most of the defaulters have suggested to minimize travel for better compliance.

% Number % NumberBetter service from local clinic 19.8 16 2.12 1Financial difficulties 12.3 10 12.76 6Traveling difficulties 28.4 23 21.27 10Drugs being taken at home properly 16 13 14.89 7Waste of time 2.5 2 4.25 2Other 21 17 44.68 21Total 100 81 100 47

Cause

Frequency

TS & TF De

% Number % Number % Number % NumberTo visit home and give the tablets daily 13.6 17 21.7 5 21.8 12 16.7 34Arranging somebody to to take you to the place 1.6 2 0 1.8 1 1.5 3Minimize travel 14.4 18 13 3 32.7 18 19.2 39Better reception at place of treatment 4.8 6 0 0 0 0 3 6To have some other health personnel/ volunteer 2.4 3 8.7 2 3.6 2 3.4 7Closer to the home to distribute drugs 39.2 49 47.8 11 18.2 10 34.5 70Other 24 30 8.7 2 21.8 12 21.7 44

Patients’ suggestions to improve compliance. TS TF De Total

69

Table 67. Relationship between consulting a private doctor and treatment outcome.

Source: IHP TB survey 2009 Majority of the patients felt that it is not necessary to consult private sector doctors.

Table 68.Education level of the DOT providers

Source: IHP TB survey 2009 Of the total DOT providers in the sample 96.7% were govt. health staff, .6% private health staff

(1) and 2.8% (5) were community DOT providers. Since most of the DOTS providers were heath

sector employees their level of education was high 75.8 % of them having a level above O level. Table 69. Employment classification of the DOT providers of the different positions

Thought of consulting a private doctor

% Number % Number % Number % NumberYes 9.2 13 3.6 1 2.7 2 6.6 16No 88.7 126 92.9 26 95.9 71 91.4 223Not Responded 2.1 3 3.6 1 1.4 1 2 5Total 100 142 100 28 100 74 100 244

TS TF De Total

% Number % Number % NumberNo formal education 0 0 0 0 0 0Up to Grade 5 0 0 0 0 0 0Up to Grade 10 3.4 6 0 0 3.3 6Up to O/L 20.1 35 33.3 2 20.6 37Up to A/L 66.1 115 66.7 4 66.1 119Tertiary education 7.5 13 0 0 7.2 13Other 2.3 4 0 0 2.2 4Not Responded 0.6 1 0 0 0.6 1Total 100 174 100 6 100 180

Level of education DOT provider PositionGovt. health staff Other Total

70

Source: IHP TB survey 2009 Majority (61.1%) were trained officers out of whom 97.3% were government officers . 35.6%

were classified as Technical & professional and they were all from the government sector. Table 70.Relationship of the training of the DOT provider to the period of been involved as a supervisor in the programme

Source: IHP TB survey 2009

It is observed that most (88.3%) of DOT providers are trained for the task. Out of those below 1

year only 38.5% are not trained. But it is noted that that out of the 21 who were not trained, 38%

(8) has still not under gone this training to be a supervisor even after being in the programme for

more than 4 years. Table 71. Modular training experience of DOT providers

Source: IHP TB survey 2009

% Number % Number % NumberTechnical and professional 36.8 64 0 0 35.6 64Administration and management 0 0 0 0 0 0Trained officer 61.5 107 50 3 61.1 110Clerical work 0 0 33.3 2 1.1 2Teacher 0 0 0 0 0 0Agriculture and farming 0 0 0 0 0 0Unskilled labourer 0.6 1 16.7 1 1.1 2Other 1.1 2 0 0 1.1 2Total 100 174 100 6 100 180

Classification Position of the DOT providerGovt. health staff Other Total

% Number % Number % Number % Number % Number % Number % Number % NumberYes 61.5 16 83.3 15 100 20 87.5 14 95.5 21 93.5 72 100 1 88.3 159No 38.5 10 16.7 3 0 0 12.5 2 4.5 1 6.5 5 0 0 11.7 21Indifferent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Trained for the task

Period Total1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded

% Number % Number % Number % Number % Number % Number % Number % NumberYes 19.2 5 66.7 12 75 15 62.5 10 68.2 15 72.7 56 100 1 63.3 114No 80.8 21 33.3 6 25 5 37.5 6 27.3 6 24.7 19 0 0 35 63Not Responded 0 0 0 0 0 0 0 0 4.5 1 2.6 2 0 0 1.7 3Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Attended DOTS modular training

programme

Period Total

1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded

71

63.3% has attended DOTS modular training programme. But it is to be noted that 49.2% of those

who had not under gone modular training had been in the programme for more than 4 years.

Table 72: Analysis of the trained for the dot provider and working experience

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results suggest that there is a statistically significant relationship between trained for the

task and working experience (p = 0.001). Most of the DOT providers who had one year

experience wer not trained for that task. Among other categories of working experience this was

not statistically significant.

Table 73. Availability of DOT manuals with the DOT providers

Source: IHP TB survey 2009

Only 54.4% of the DOT providers had the manual with them even though 63.3% had been

trained on the module (Ref. Table 50)

1 Year 2 Years 3 Years 4 Years 5 YearsMore than

5 YearsYes 16 15 20 14 21 72

(-1.45) (-0.22) (0.56) (-0.03) (0.36) (0.49)No 10 3 0 2 1 5

(3.98**) (0.61) (-1.53) (0.09) (-0.98) (-1.34)Fisher's exact = 0.001

Period

Trained forthe task

% Number % Number % Number % Number % Number % Number % Number % NumberYes 23.1 6 55.6 10 80 16 68.8 11 54.5 12 54.5 42 100 1 54.4 98No 76.9 20 44.4 8 20 4 31.3 5 45.5 10 45.5 35 0 0 45.6 82Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Manual on DOT

available with him

Period Total

1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded

72

Table 74: Analysis of attending to DOTS modular training and working experience

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

These results suggest that there is a statistically significant relationship between attended DOTS

modular training program and working experience (p = 0.000). Most of those who had one year

working experience had not attended DOTS modular training program. Table 75.Relationship of the knowledge on TB and DOTS strategy as perceived by the DOT provider to the period of been involved as a supervisor in the programme

Source: IHP TB survey 2009 90% of the DOT providers have perceived that they do have knowledge on TB and it has

improved with years of experience. Out of those who perceived that they have no knowledge

64.7% were involved for less than 4 years in the programme.

1 Year 2 Years 3 Years 4 Years 5 YearsMore than

5 YearsYes 5 12 15 10 15 56

(-2.86**) (0.13) (0.60) (-0.09) (0.41) (1.13)No 21 6 5 6 6 19

(3.83**) (-0.17) (-0.81) (0.11) (-0.55) (-1.51)Pearson chi2(5) = 28.0129 Pr = 0.000

Attended DOTS modular training

program

Period

% Number % Number % Number % Number % Number % Number % Number % NumberYes 65.4 17 94.4 17 90 18 100 16 86.4 19 96.1 74 100 1 90 162No 34.6 9 5.6 1 5 1 0 0 13.6 3 3.9 3 0 0 9.4 17

Not Responded 0 0 0 0 5 1 0 0 0 0 0 0 0 0 0.6 1

Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Knowledge on TB

Period

1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded Total

73

Table 76: Analysis of knowledge on TB and working experience

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009 These results suggest that there is a statistically significant relationship between knowledge on TB and work experience of the DOT providers (p = 0.001). If the DOT provider had more than one year working experience he/she may have good knowledge on TB as expected. Table 77. Relationship of familiarity with the concept of DOTS as perceived by the DOT provider to the period of had been involved as a supervisor in the programme.

Source: IHP TB survey 2009 83.3% of the DOT providers were familiar with the concept of DOTS. But it is noted that out of

those who were not familiar 55% had been in the programme for more than 4 years.

Table 78: Analysis of familiarity with DOTS and working experience

Note: standardized residual values (z) in parenthesis. ** and * indicate significance at 1% and 5% respectively. Source: IHP TB survey 2009

1 Year 2 Years 3 Years 4 Years 5 YearsMore than

5 YearsYes 17 17 18 16 19 74

(-1.34) (0.18) (0.20) (0.40) (-0.20) (0.52)No 9 1 1 0 3 3

(4.14**) (-0.55) (-0.60) (-1.24) (0.62) (-1.61)Fisher's exact = 0.001

Knowledge on TB Period

% Number % Number % Number % Number % Number % Number % Number % NumberYes 80.8 21 72.2 13 85 17 81.3 13 81.8 18 87 67 100 1 83.3 150No 19.2 5 27.8 5 15 3 18.8 3 18.2 4 11.7 9 0 0 16.1 29Not Responded 0 0 0 0 0 0 0 0 0 0 1.3 1 0 0 0.6 1Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Familiarity with the

concept of DOTS

Period

1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded Total

1 Year 2 Years 3 Years 4 Years 5 YearsMore than

5 YearsYes 21 13 17 13 18 67

(-0.16) (-0.53) (0.06) (-0.11) (-0.10) (0.42)No 5 5 3 3 4 9

(0.37) (1.21) (-0.14) (0.24) (0.22) (-0.96)Fisher's exact = 0.606

Familiarity with the concept of

DOTS

Period

74

These results suggest that there is no statistically significant relationship between familiarity with

the concept of DOTS of the DOT providers and working experience (p = 0.001). Table 79.Relationship of awareness of DOTS strategy as perceived by the DOT provider before being a DOT supervisor

Source: IHP TB survey 2009 75.6% of the DOT providers had not been aware of DOTS strategy before being recruited as a

DOT supervisor even though they are mostly government health staff. Table 80.Mode of acquiring knowledge regarding TB by the DOT providers

Source: IHP TB survey 2009 72.4 % of the Govt. health staff has acquired knowledge regarding TB from the DOTS training.

But it is observed that only 16.7% in the other group has benefitted from DOTS training.

Significant numbers of the DOT providers has used literature, mass media and other means to

acquire additional knowledge.

% Number % Number % Number % Number % Number % Number % Number % NumberYes 26.9 7 27.8 5 35 7 18.8 3 13.6 3 22.1 17 100 1 23.9 43No 69.2 18 72.2 13 65 13 81.3 13 86.4 19 77.9 60 0 0 75.6 136Not Responded 3.8 1 0 0 0 0 0 0 0 0 0 0 0 0 0.6 1Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

Awareness of DOTS strategy before being

a DOT supervisor

Period1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded Total

% Number % Number % NumberDOTS training 72.4 126 16.7 1 70.6 127Chest Clinic 31.6 55 66.7 4 32.8 59Literature 16.7 29 16.7 1 16.7 30Mass media 15.5 27 33.3 2 16.1 29Other 11.5 20 16.7 1 11.7 21

Mode of acquiring knowledge

Position of the DOT providerGovt. health staff Other Total

75

Table 81.DOTS providers views regarding DOTS vs. the previous methods of TB control to the period of been involved as a supervisor in the programme.

Source: IHP TB survey 2009 92.2% of the DOT providers feel that DOTS is better than the previous method. Out of those

who said no 75% (9) were involved for more than 5 years (5% of all DOT providers).

Table 82.Reasons given by the DOT providers for saying that DOTS is better than the previous method for TB control activities

Source: IHP TB survey 2009 Note : Totals do not add up to sample size due to multiple responses to the question

Out of the 166 who had said that DOT is better than previous method of TB control, most of

them said that the patient compliance was better with DOTS and the cure rate was higher. Some

of them felt that the default rate could also be reduced and early action could be initiated if side

effects developed or if the patient interrupt treatment by adopting this method

% Number % Number % Number % Number % Number % Number % Number % NumberYes 92.3 24 88.9 16 100 20 100 16 100 22 87 67 100 1 92.2 166No 3.8 1 11.1 2 0 0 0 0 0 0 11.7 9 0 0 6.7 12Not Responded 3.8 1 0 0 0 0 0 0 0 0 1.3 1 0 0 1.1 2Total 100 26 100 18 100 20 100 16 100 22 100 77 100 1 100 180

DOTS is better than the

previous method for TB control

activities

Period

1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs >5 yrs. Not Responded Total

Reasons% Number

Cure rate is higher 61.7 111Patients’ compliance is better 72.2 130Low default rates 52.2 94Can take early actions when side effects develop 40.6 73Can take early action when patients interrupt treatment 43.3 78Other 5.6 10

Frequency

76

Table 83.a DOT providers views regarding the necessity of DOT at a DOT center for TB patients.

Source: IHP TB survey 2009 Table 84.b DOT providers views regarding the categories that do not need DOT at a DOT center

Source: IHP TB survey 2009 Only 50.6% of the DOT providers said that DOT at a DOT center is necessary for all patients.

Out of those (87) who said it was not necessary 58 of the DOT providers felt that for children <5

years it was not needed and 45 said that it is not necessary for professionals.

Table 85.Number of patients that the DOT provider is supervising at the moment to the position of the DOT provider

Source: IHP TB survey 2009 In this random sample 19.4% of the DOT providers interviewed had no patients for supervision

at the time of the interview. 60% of the DOT providers had 1 - 4 patients. 21.3% of the

government staff had more than 5. It is also noted that 12.2% of them had more than 10 patients.

% NumberYes 50.6 91No 48.3 87Not Responded 1.1 2Total 100 180

Necessary for all TB

patientsFrequency

% NumberNot necessary for Professionals 22.1 45Children <5 yrs. 28.4 58School children 21.1 43Health personnel 20.1 41Other 8.3 17Total 100 204

DOT need Category Frequency

% Number % Number % Number % Number % NumberGovt. health staff 19 33 59.8 104 8.6 15 12.6 22 100 174Other 33.3 2 66.7 4 0 0 0 0 100 6Total 19.4 35 60 108 8.3 15 12.2 22 100 180

PositionNumber of patients

No patients 1 – 4 5 – 9 10 or above Total

77

Table 86.Mode of acquiring knowledge about DOTS in relation to the position of the DOT provider

Source: IHP TB survey 2009 Note : Totals do not add up to sample size due to multiple responses to the question

Majority of the DOT providers (52%) had acquired knowledge about DOTS after being recruited

as a DOT provider. Only 8 (3.3%) had acquired the knowledge in their basic training even

though large majority of them were health staff.

Table 87.Knowledge of the DOT provider about the disease and management as perceived by the interviewer

Source: IHP TB survey 2009 Only one DOT provider has been graded as highly unsatisfactory in their knowledge on the

treatment categories and the regimen but none regarding their knowledge on the other factors

mentioned. Most of the DOT providers has been graded as satisfactory in their knowledge about

the disease, DOTS, duration of treatment and about the important TB messages. But the

knowledge on treatment categories and the regimen has been graded as fair or unsatisfactory in

55.5% of the DOT providers. Also 52.3% of them have been graded as fair or unsatisfactory on

the awareness of the side effects.

% Number % Number % NumberIn undergraduate training 3.4 8 0 0 3.3 8After joining health dept. 23.6 56 0 0 23 56After joining NPTCCD 7.2 17 0 0 7 17Mass media & internet 8.4 20 14.3 1 8.6 21In postgraduate training 0 0 0 0 0 0In basic training (MLT/Pharmacist/Dispenser) 3.4 8 0 0 3.3 8After being recruited as a DOT provider 51.5 122 71.4 5 52 127Other (Specify) 2.5 6 14.3 1 2.9 7

Mode PositionGovt. health staff Other Total

% Number % Number % Number % Number % Number % Number % NumberAbout the disease 19.4 35 46.1 83 28.9 52 5 9 0 0 0.6 1 100 180About DOTS 11.1 20 42.8 77 36.1 65 9.4 17 0 0 0.6 1 100 180Treatment categories and regimen 13.3 24 30 54 37.2 67 18.3 33 0.6 1 0.6 1 100 180Awareness of side effects 9.4 17 37.2 67 36.7 66 15.6 28 0 0 1.1 2 100 180Duration of treatment 15.6 28 45.6 82 28.3 51 9.4 17 0 0 1.1 2 100 180Important TB messages 13.3 24 47.2 85 32.8 59 4.4 8 0 0 2.2 4 100 180

Not Responded TotalKnowledge of DOT provider

Highly satisfactory Satisfactory Fair Unsatisfactory Highly unsatisfactory

78

Table 88. Action taken by DOT providers when patients interrupt treatment.

Source: IHP TB survey 2009

All the DOT providers in the non-govt. category have gone to the patients' places to trace when

interrupted treatment while informing the other relevant personnel. Only 31 out of 174 govt.

DOT providers had gone to the patients’ places to trace them. Most of the govt. DOT providers

had informed DTCO, chest clinic PHI or any other in the chest clinic

% Number % Number % Number27.6 48 33.3 2 27.8 50

4 7 0 0 3.9 717.8 31 100 6 20.6 37

Inform the chest clinic DTCO 68.4 119 33.3 2 67.2 121PHI of chest clinic 56.9 99 16.7 1 55.6 100other 1.1 2 0 0 1.1 2over phone 36.8 64 0 0 35.6 64By letter 6.3 11 0 0 6.1 11

20.1 35 16.7 1 20 3617.8 31 33.3 2 18.3 33

8 14 0 0 7.8 1415.5 27 16.7 1 15.6 28

4 7 16.7 1 4.4 8100 174 100 6 100 180

Inform head of the institutionOthersTotal

Send a letter to the patientGo to the patient's place and contact him or her

Inform MOHInform PHIInform the officer in charge of the DOT provider

Action taken PositionGovt. health staff Other Total

Call patient if contact number is available

79

Table 89.Frequency distribution of constraints faced or experienced in implementation of DOT at the DOT center in relation to the position

Source: IHP TB survey 2009 Note : Totals do not add up to sample size due to multiple responses to the question

Most of the DOT providers in the govt sector and the non- government has mentioned that the

poor facilities at the DOT center as a constraint. 63 of the govt. DOT providers have faced with

the difficulty in tracing the patients while 44 of them have mentioned that the corporation of the

patients was poor. 30 of the govt. DOT providers had felt lack of time due to high work load was

a constraint.

Table 90. The drug supply to the DOT center and the storage of drugs at the DOT center

Source: IHP TB survey 2009 The drug supply to 3.4% of the govt. DOT centers has not been satisfactory. It has been observed

that drugs were out of stock at 8 centers in the government sector. Drug storage has not been

% Number % Number % NumberPoor facilities at the DOT center 40.8 71 66.7 4 41.7 75Difficulty in tracing the patients once they interrupt treatment 36.2 63 0 0 35 63Poor cooperation of the patients 25.3 44 0 0 24.4 44No time due to heavy work load with other work 17.2 30 0 0 16.7 30Not being trained adequately for DOTS 3.4 6 33.3 2 4.4 8Inadequate and irregular drug supply to the DOT center 4 7 0 0 3.9 7Inadequate staff cooperation 4 7 0 0 3.9 7Difficulties in monitoring 3.4 6 0 0 3.3 6Inadequate managerial support 2.9 5 0 0 2.8 5Other (Specify) 2.9 5 0 0 2.8 5Difficulties in reporting and feedback 1.7 3 0 0 1.7 3Inadequate guidance 1.1 2 0 0 1.1 2Total 100 174 100 6 100 180

Constraint PositionGovt. health staff Other Total

% Number % Number % Number % NumberDrug supply is satisfactory (Q 37G) 94.3 164 3.4 6 100 6 0 0Any of the drugs out of stock for more than one month 8 14 89.7 156 16.7 1 83.3 5Drugs stored without exposure to sunlight 89.7 156 8 14 100 6 0 0Drugs are kept separately for each patient 89.7 156 8 14 100 6 0 0Drugs are labeled 89.7 156 7.5 13 100 6 0 0Drugs are placed in containers 94.3 164 3.4 6 100 6 0 0Drugs are kept safely under lock and key 64.9 113 33.3 58 50 3 50 3

Drug supply / storage

PositionGovt. health staff(174 ) Other(6)

Yes No Yes No

80

maintained as expected to be in 14 (8 %) govt. DOT centers but in the private DOT centers it is

as expected to be. Drugs have not been kept under lock and key in 58(33%) of govt. DOT centers

and in 3 out of 6 private DOT centers

Table 91. Availabilty of facilities at the DOT centers in different types of government health institutions as observed by the Interviewer

Source: IHP TB survey 2009

Very few of the govt. health institutions (30.8%) have a separate place for DOT. The location of

the DOT center was easy to find in almost all (97.6%) of the institutions but comparatively less

in BHs (87.5%). Instruction leaflets & HE material was not available in many DOT centers in all

types of govt. health institutions. Availability of safe water was found only in 58% of the DOT

centers in the govt. health institutions. Even availability of drug containers waste disposal bins

were not adequate in most places

Table 92.Maintenance of DOT registers and supervision of DOT Centers in government health institutions

Source: IHP TB survey 2009 DOT registers were maintained only in 65.5% of the DOT centers. The uniformity of the

register within the district has been maintained in Most of the DHs (83.3%) and in PUs (83.3%)

but not in others. Daily update of the treatment cards has been observed in 93.1% of the DOT

TelephoneChair and other seating facilitiesSafe waterDrug cupboardDrug containerSharp binWaste disposal binsInstruction leafletsHE material

Total(

15.4 2 47.1 24 25.321.3

25 4 6.7 3 27.8 10 7.7 115.4 2 23.1 3 27.5 1425 4 8.9 4 27.8 10

61.5 8 60.8 31 52.943.7

56.3 9 26.7 12 66.7 24 61.5 869.2 9 69.2 9 39.2 2037.5 6 17.8 8 66.7 24

84.6 11 56 28 66.571.3

68.8 11 71.1 32 66.7 24 69.2 961.5 8 84.6 11 64.7 3387.5 14 66.7 30 77.8 28

69.2 9 62.7 32 5873

50 8 46.7 21 69.4 25 46.2 684.6 11 76.9 10 72.5 3768.8 11 60 27 86.1 31

76.9 10 66.7 34 59.283.5

68.8 11 53.3 24 50 18 46.2 684.6 11 92.3 12 90 45

48 97.6 Comfortable place 75 12 69 29 91.7 33

35 100 13 100 13 98Easy Access and location of the DOT center 87.5 14 100 43 97.223.1 3 46 23 30.8Separate place for DOT 31.3 5 9.1 4 41.7 15 23.1 3

Number % Number % Number %% Number % Number % Number %

1/DH(36) 1/PU(13) 1/RH(13) Other(51)Facility 1/BH(16) 1/CD(45)

% Number % Number % Number % Number % Number % NumDOT register available 81.3 13 65.1 28 80.6 29 84.6 11 69.2 9 49DOT register is uniform with the same in the district 53.3 8 76.5 26 83.3 25 83.3 10 50 5 58.8Treatment cards are daily updated 93.8 15 88.6 39 97.2 35 100 13 92.3 12 100Remarks on supervision of the DOT center by DTCO/PHI available 56.3 9 34.1 14 33.3 12 58.3 7 30.8 4 43.8

Other(51)State of DOT register 1/BH(16) 1/CD(45) 1/DH(36) 1/PU(13) 1/RH(13)

81

centers. Written reports on supervision of the DOT center by DTCO/PHI had not been recorded

or maintained in most of the DOT centers.

Table 93. Frequency distribution of DOT providers in government health institutions and private hospitals

Source: IHP TB survey 2009 In this sample in most of the selected districts it is observed that in the govt. institutions,

dispensers (30.5%) were the main category recruited as DOT providers. The next highest

category was the nursing officers (22.8%). The number of minor staff serving as DOT providers

was 37 (15%) which is still significant. The involvement of the PHMs and PHIs are 4.5% &

5.7% respectively and less than the involvement of minor staff and even pharmacists (8.9%).

Table 94.Average number of DOT providers working at a DOT center

Source: IHP TB survey 2009

Most of the DOT centers had an average of 4 trained DOT providers per center.

% Number % Number % NumberDispensers 30.5 75 0 0 29.8 75Nursing officer 22.8 56 0 0 22.2 56Minor staff 15 37 16.7 1 15.1 38Pharmacist 8.9 22 0 0 8.7 22PHI 5.7 14 0 0 5.6 14MO 4.9 12 0 0 4.8 12PHM 4.5 11 16.7 1 4.8 12Other (Specify) 3.3 8 66.7 4 4.8 12RMO 4.5 11 0 0 4.4 11

DOT providers

InstitutionGovernment i tit ti

Other Total

Category

Government Other TotalAverage number of DOT providers working at the DOT center at present 4.27 1 4.18Number of trained DOT providers 4.02 1.2 3.94

Category Institution

82

9.Bibliography 1. Sunil Bernard De Alwis, Provincial Director of Health Services, North Western Province, Sri Lanka

“An assessment of the impact of a DOTS programme in North Western Province, Sri Lanka” http://www.tropika.net/specials/forum11/schedule/a162.html

2. Katherine Floyd, VK Arora, KJR Murthy, Knut Lonnroth, Neeta Singla, Y Akbar, Matteo Zignol, & Mukund Uplekar “Cost and cost-effectiveness of PPM-DOTS for tuberculosis control: evidence from India” http://www.who.int/bulletin/volumes/84/6/437.pdf

3. Vary Jacquet, Willy Morose, Kevin Schwartzman, Olivia Oxlade, Graham Barr, Franque Grimard and Dick Menzies 2 “Impact of DOTS expansion on tuberculosis related outcomes and costs in Haiti” http://www.hawaii.edu/hivandaids/Impact_of_DOTS_expansion_on_tuberculosis_related_outcomes_and_costs_in_Haiti.pdf

4. Wright J, Walley J, Philip A, Pushpananthan S, Dlamini E “Direct observation of treatment for tuberculosis: a randomized controlled trial of community health workers versus family members.” Tropical Medicine and International Health, 2004 May; 9(5):559-565. http://www.popline.org/docs/192447

5. Walley JD, Khan MA, Newell JN, et al. “Direct observation of tuberculosis treatment did not promote higher cure rates than self administered treatment” Lancet 2001 Mar 3;357:664–9.[Medline] Evidence-Based Medicine 2001; 6:142 © 2001 Evidence-Based Medicine

6. WHO Recommended Strategy for TB Control: DOTS http://www.cgcptd.health.kiev.ua/tbcontrol/eng/set_up_DOTS.htm

7. WHO fact Sheets http://www.who.int/mediacentre/factsheets/fs104/en/

83

1

Annexes

2

Annexure1: Draft Report of the workshop

Date – 24th November 2009

Auditorium/NPTCCD

GFATM – TB Operational Research Study for “Evaluation of the

Effectiveness of the National DOTS Programme” Note for Record

Participants

Dr.Sunil De Alwis, D/NPTCCD

Dr.Rohitha Dharmasiri, DTCO/Colombo Chest Clinic

Dr.D.Wijesinghe, MO/Welisra Chest Clinic

Dr.Anoma De Silva, DTCO/Kandy Chest Clinic

Dr.Ajith Kariyawasam, DTCO/Galle

Dr.S.Mahanama, DTCO/Rathnapura

Dr.W.M.D.N.K.Wijesinhe ,DTCO/Kurunegala

Dr.Suresh Kumar, DTCO/Trincomalee

Mr.L.D.A.N.Kumarasinghe, PHI/Colombo Chest Clinic

Mr.K.U.Shantha, PHI/ Colombo Chest Clinic

Mr.K.S.Ranasinghe, PHI/ Colombo Chest Clinic

Mr.K.A.R.S.Weerakoon, PHI/ Colombo Chest Clinic

Mr.D.Wickramaratne, PHI/Gampaha

Mr.Y.Rathnayake, PHI/Gampaha

Mr.M.Bandara, PHI/Kalutara

Mr.S.Fernando, PHI/Kalutara

Mr.Chanaka Hewawasam, PHI/Kandy

Mrs.Indra Kumari, PHI/Kandy

Mr.Gunasekara, PHI/Galle

Mr.Udaya Gunaratne, PHI/Rathnapura

Mr.B.M.S.O.G.Balasooriya, PHI/Kurunegala

Mr.T.Sivakumara, PHI/Trincomalee

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IHP

Dr.Shanti Dalpatadu, Senior Fellow

Dr.Kasun Chandradasa, Research Intern

Dr.Achana Obris, Research Intern

Excuses

Dr.Samaraweera, Consultant Community Physician/NPTCCD

Dr.Ruwanie Perera, DTCO/Colombo Chest Clinic

Dr.Deepthi Waidyaratne, DTCO/Anuradhapura

Mr.Indika Thilakaratne, PHI/Aniradhapura

Absent

Dr.K.K.Abeyweera, DTCO/Kalutara

Mr.Vajira Rathnayake, PHI/Kurunegala

• Dr. Achana Obris welcomed the participants on behalf of Institute for Health Policy and gave a

brief introduction to the work shop and the programme.

• Dr. Sunil De Alwis D/NPTCCD addressed the gathering and said that this was a important

operational research study for improving the management aspects of the DOTs programme in Sri

Lanka and requested the participants to give their fullest cooperation to the IHP research team to

carry out the field survey.

• Dr.Shanti Dalpatadu explained the objectives of the workshop.

• This was followed by a presentation and discussion on the methodology and guidance for

conducting the field survey.

• He informed that this survey will be done in 9 selected districts and the sample will represent

70% sputum positive patients reported during the first three quarters of the year 2008.

• Target population selected for the study was all new sputum positive cases registered 12 to 15

months prior to commencement of the TB study and randomly selected DOTS providers from the

same district and who were active during the same time period. Three categories of patients were

to be selected from the sample. Those who were categorized as:

Treatment success

Treatment failures &

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Defaulters

• He said that three interviewer administered questionnaires were prepared field tested and

finalized with the assistance of technically competent external consultants with experienced in the

National TB control programme.

For the Treatment success and Treatment failures there was one single questionnaire.

And there were separate questionnaires for Defaulters and DOTS providers.

• Questionnaires for Treatment success and Treatment failures were to be completed by the

relevant PHIs of the districts. Dr Shanti instructed 10% of these to be cross checked by the

DTCO of the relevant district for consistency.

• DOTS providers’ questionnaire was to be completed by the DTCOs.

• Survey teams were informed to carry out the survey of patients and DOT providers without

interrupting their day to day activities during working hours while doing routine field work as

well as during off hours.

• Survey to commence on 1st December 2009 and end by 31st January 2010. All completed

Questionnaires to be forwarded to IHP within 2 months.

• Although the PHIs requested for an extension of the time period as it involved additional time

specially in tracing Defaulters. Dr. Shanti Dalpatadu regretted saying that this cannot be done due

to the limited time period available for the study

• He asked the participants to send all completed questionnaires to IHP through the DTCO by

registered post once a week or in 10 days till all the assigned patients and DOT providers were

surveyed.

• The three questionnaires and guidelines were presented and discussed by Dr. Shanti Dalpatadu in

detail. All queries were taken into consideration and clarifications were given to questions and

issues raised as regards to content in the questionnaires and in conducting the survey.

• As compensation and an incentive for doing this survey it was informed that

Each PHI will be paid Rs.250 per completed questionnaire

DTCO’s will also be paid Rs.250 per completed questionnaire in addition Rs.5000 will be

paid for providing supervision and guidance to the PHIs for conducting the survey.

• If the PHIs have come across any issues or needs any clarifications while conducting the survey

they should contact their DTCOs. And if the DTCO needs any clarification he/she may contact

the research team at the Institute for Health Policy.

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• All the PHIs and the DTCOs were given invoices to be filled up and send back to the IHP after

they have completed all the work. They were told that payment can be done at the end or a

halfway payment can be done.

• PHIs requested that they need to have a letter from the D/NPTCCD to the DTCOs stating that

they have been given permission to conduct this survey during their working hours while doing

their routine field work as well as off hours.

• Dr. Shanti Dalpatadu agreed to get a letter of permission from the D/NPTCCD and promised to

send it to the DTCOs within next couple of days.

• Participants were registered and were assigned an enumerators number to be used in case there is

a need to trace the questionnaires they have completed .(Annex 1)

• Finally all the questionnaires were handed over to the relevant districts.

All the participants were given a registration number.

DTCOs

D1-Dr. Ruwanie Perera, DTCO/Colombo Chest Clinic

D2-Dr.Rohitha Dharmasiri, DTCO/Colombo Chest Clinic

D3-Dr.P.V.D.S.Francis,DTCO/Welisra Chest Clinic

D4-Dr.Abeyweera, DTCO/Kalutara

D5-Dr.Anoma De Silva, DTCO/Kandy Chest Clinic

D6-Dr.Ajith Kariyawasam, DTCO/Galle

D7-Dr.S.Mahanama, DTCO/Rathnapura

D8-Dr.W.M.D.N.K.Wijesinhe ,DTCO/Kurunegala

D9-Dr.Deepthi Waidyaratna, DTCO/Anuradhapura

D10-Dr.Suresh Kumar, DTCO/Trincomalee

PHIs

P1-Mr.L.D.A.N.Kumarasinghe, PHI/Colombo Chest Clinic

P2-Mr.K.U.Shantha, PHI/ Colombo Chest Clinic

P3-Mr.K.S.Ranasinghe, PHI/ Colombo Chest Clinic

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P4-Mr.K.A.R.S.Weerakoon, PHI/ Colombo Chest Clinic

P5-Mr.D.Wickramaratne, PHI/Gampaha

P6-Mr.Y.Rathnayake, PHI/Gampaha

P7-Mr.M.Bandara, PHI/Kalutara

P8-Mr.S.Fernando, PHI/Kalutara

P9-Mr.Chanaka Hewawasam, PHI/Kandy

P10-Mrs.Indra Kumari, PHI/Kandy

P11-Mr.Gunasekara, PHI/Galle

P12-Mr.Udaya Gunaratne, PHI/Rathnapura

P13-Mr.Vajira Rathnayake, PHI/Kurunegala

P14-Mr.B.M.S.O.G.Balasooriya, PHI/Kurunegala

P15-Mr.Indika Thalakaratna, PHI/Anuradhapura

P16-Mr.T.Sivakumara, PHI/Trincomalee

Annexure 2: Guidelines for Administering Questionnaires

Guidelines for Administering Questionnaires Operational Research Study for “Evaluation of the effectiveness of the National DOTS

Programme and to develop alternate models to improve of DOTS treatment in various settings”.

This is an interviewer administered questionnaire & PHIs attached to the chest clinics of selected

districts will conduct the interview and complete the questionnaires after tracing selected sample

of cases from their districts.

Selection of patients

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Questionnaire No. 1 is for patients whose treatment outcome is categorized as

1) Treatment success

‘New’ sputum smear positive patients registered in the first 3 quarters in 2008 who have been treated

successfully

2) Treatment failure

‘New’ sputum smear positive patients registered in the same period who have failed treatment

(Re-registered later as ‘Treatment after Failure’ and may be still on Cat II treatment at the time

of administering the questionnaire) Questionnaire No. 2 Is for Defaulters.

1) ‘New’ sputum smear positive patients registered in the first 3 quarters in 2008 who have

defaulted treatment

2) ‘New’ sputum smear positive patients registered initially in the same period who have

defaulted and returned for treatment later (Re-registered later as ‘Treatment after Default’ and

may be still on Cat II treatment at the time of administering the questionnaire)

Except for the three districts in the Western Province all ‘New’ sputum smear positive TB

patients categorized as ‘Treatment Failure’ and ‘Default’ as the treatment outcome will be

included for the survey.

A matching number of ‘New’ sputum smear positive patients categorized as ‘Treatment

Success’ as the outcome should be randomly selected for these districts.

In Western Province;

Sample frame for the ‘New’ sputum - smear positive TB patients categorized ‘Default’ as the

outcome will be provided. Interviews should be continued until the required number for this

category is interviewed.

All ‘New’ sputum - smear positive TB patients categorized as ‘Treatment Failure’ as the

outcome will be included.

A matching number of ‘New’ sputum - smear positive patients categorized as ‘Treatment

Success’ as the outcome should be randomly selected for these districts also and interviewed.

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Note: Only the New Sputum - smear Positive patients falling in to the mentioned treatment

outcome categories are included in the sample.

Regarding the questionnaires Questionnaire includes some general core demographic information and some other questions to

assess the various aspects of the ’Directly Observed Treatment’.

Note The questionnaire for defaulters has been designed to collect details from ‘New’ TB

patients registered in the first 3 quarters in 2008 who have defaulted treatment. Among these

defaulters there may be some patients who have been restarted on treatment (CAT 2) and

currently on CAT 2 regimen. They also must be included, since they have defaulted CAT I

treatment when in the diagnostic category of ‘New’. Those patients should be administered with

the same questionnaire and it should be carried out with extra caution. When you are

interviewing these patients (defaulter who has restarted treatment) you should advise them that

they should answer the questions as they were defaulters. The interview should be carried out in

such a way that the questions and answers are directed for the period before they were registered

in the Retreatment category (i.e. while on CAT I treatment and during defaulted period).

In order to ensure anonymity of patients’ responses, the following procedures are appropriate

when you are filling the questionnaires.

Please tick the relevant box in front of the responses and if you happen to choose “Other’’ as a

response, please do not forget to specify the patient’s response.

Questions 1) to 19) include general demographic details of the patient and most of them are very

straight forward questions. Q15A), ‘Number of pack years’ means a way to measure the

amount a person has smoked over a long period of time. It is calculated by multiplying the

number of packs of cigarettes smoked per day by the number of years the person has smoked.

Number of Pack Years = (Packs smoked per day) x (years as a smoker)

Or

Number of pack years = (number of cigarettes smoked per day x number of years smoked)/20 (1 pack has

20 cigarettes).

Q 15 A) and Q 16 B), responders can use more than one substance at a time and if it is so, you may tick

more than one box.

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Q 20) Give the correct date he/she was diagnosed as having TB for the first time following microscopic

examination of the sputum.

Q 21A) you have to find the date on which he/she has started treatment as a new TB patient for the first

time i.e. CAT 1 regimen. This date may differ from the date given in Q 20) or may be the same.

Q 31) is an open ended question and for us to make analysis easier try to be specific in your answers.

Q 36) in questionnaire 1 and Q 37) in questionnaire 2 is only applicable to responders who have selected

response No 2 for Q 34A), 35A) in questionnaire 1 and Q 35A), Q 36A) in questionnaire 2. Here they can

choose more than one response. Mark them according to their preference. 1, 2, 3 etc.

Following guidelines are specifically for Questionnaire No. 2 (Defaulters)

Q 21 B) To be filled only if the responder is a defaulter who has come back for re treatment. Then the

date when he/she restarted the treatment under CAT 2 regimen.

Q 22) if you are interviewing a defaulter who has come back for re treatment, the nearest chest clinic

would be the clinic where he had gone for his CAT 1 treatment.

Q 64), Q 66) and Q 67B) are only for defaulters who have started re treatment and currently being on

CAT 2 regimen.

General Instructions You may use English, Sinhalese or the Tamil questionnaire forms. But it will be better if you could use

one (language) of the above for all patients that you will be interviewing.

Please get answers to all questions and complete the entire questionnaire and do not leave any blanks.

Try to get the Patients to respond to your questions with minimal prompting to get their frank answers

and opinions to the questions posed.

If there is more than one response to some of the questions rank those up to three according to the

patient’s view of importance or priority.

Make sure that your hand writing is legible to read when entering answers to open ended questions.

Ensure that the form for consent to participate is annexed to each completed questionnaire.

Make every effort to trace the Defaulters and the Treatment failures by visiting at least three times as the

numbers in the sample is small.

All completed questionnaires should be sent through your supervising DTCO weekly to Institute for

Policy Studies till the survey is completed.

If any questions or queries should arise while conducting the survey please contact your DTCO. For

further verifications the DTCO may contact,

Dr Kasun Chandradasa,

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Institute for Health Policy,

No. 72, Park Street,

Colombo 2.

Phone. 011 231 4041/4042/4043/4045

Email.kasun@ihp.lk

Annexure 3: Consent Form for the Patients

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CONSENT FORM FOR THE PATIENTS PARTICIPATING in the

“Evaluation of the effectiveness of the National DOTS Programme and to develop

alternate models to improve of DOTS treatment in various settings”.

We, the Institute for Health Policy (IHP) is undertaking the above study on

behalf of the Ministry of Health to evaluate the effectiveness of National DOTS

programme and to develop alternate models to improve provision of DOTS

treatment in Sri Lanka.

We would like to invite you to participate in this research project. You should

only participate if you want to; choosing not to take part will not disadvantage you

in any way. Before you decide whether you want to take part, it is important for

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you to understand why the research is being done. And what your participation will

involve.

Our field Research Investigator PHI attached to your area TB chest clinic will

explain and educate you in this regard. He will specifically explain in detail the

purpose of this, what is expected from you. You may ask him if there is anything

that is not clear or if you would like more information.

We appreciate your willingness to contribute to the successful conduction of this

survey. Please take a little time and read the consent document annexed and if you

agree give your consent to be a study participant by signing this consent form

before you start answering the questionnaire.

Thanking you.

Dr.K.C.Shanti.Dalpatadu

Research Team Leader

Senior Fellow

IHP NSENT FORM FOR PARTICIPANTS

Serial number:

Name of the Central Chest clinic:

Respondent Identification Number for study:

Please complete this form after you have listened to an explanation about this research study.

Title of Study: “Evaluation of the effectiveness of the National DOTS Programme and to develop

alternate models to improve of DOTS treatment in various settings”.

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Thank you for considering taking part in this research. The person organizing the research must

explain the project to you before you agree to take part.

I confirm that I have been well informed by the research investigator regarding above study and

understood the purpose of the study

I have had the opportunity to consider the information, ask questions and have had these

answered satisfactorily

I understand that my participation is voluntary and that I am free to withdraw at any time,

without giving any reasonf I no longer wish to participate in this project and I can notify the

researchers involved to be withdrawn from it immediately.

I consent to the processing of my personal information for the purposes of this research study. I

understand that such information will be treated as strictly confidential.

I understand that relevant sections of any of my medical notes and data collected during the

study may be looked at by responsible individuals from IHP where it is relevant to my taking

part in this research. I give permission for them to have access to my records

Participant’s Statement:

I _____________________________________________________________________

Agree that the research project named above has been explained to me to my satisfaction and I

agree to take part in the study. I understand what the research study involves.

Signed …………………………………………….. Date …………………………..

Investigator’s Statement:

I _____________________________________________________________________

confirm that I have carefully explained the nature, of the proposed research to the volunteer.

Signed …………………………………………….. Date …………………………..

Researchers Statement (IHP)

Confirmed as acceptable

Signed …………………………………………….. Date …………………………..

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Annexure 4: Questionnaire No:1 for the TB Patients

Serial number-

District code –

Respondent identification Number –

All Information collected at this questionnaire will be treated as strictly confidential.

Questionnaire for Evaluation of the effectiveness of the National DOTS Programme

Questionnaire No. 1 for TB patients in outcome category of Treatment Success & Treatment failure of CAT 1 (Including those who are now on treatment as CAT 2)

1) Name of Patient …………………………………………………………………………………………………………………

2) District TB Number …………………………………………………………………………………………………………………

3) Diagnostic Category ………………………………………………………………………………………………………………….

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4) MOH area …………………………………………………………………………………………………………………

5) Age (Years) ………………………………………….............................................................................................................

1. <15 Years

2. 15 – 24 Years

3. 25 – 34 Years

4. 35 – 44 Years

5. 45 – 54 Years

6. 55 – 64 Years

7. 65 – 74 Years

8. > 75 Years

6) Sex

1. Male 2. Female

7) Permanent Address ……………………………………………………………………………………………………………………………………….

8) Current place of residence

1. In a permanent residence (own or rented house) 2. In a temporary residence 3. Relative’s house 4. Boarding house 5. Hostel 6. Work place 7. Street 8. Prison

9) Ethnicity

1. Sinhalese 2. Tamil 3. Muslim 4. Burgher

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5. Other ( Specify)

10) Level of education

1. No formal Education 2. Up to Grade 5 3. Up to Grade 10 4. Up to O/L 5. Up to A/L 6. Tertiary education 7. Other ( Specify)

11) Marital status

1. Married 2. Unmarried 3. Divorced 4. Separated 5. Widowed

12) No. of children …………………………………

13) Occupation

1. Unemployed 2. Self employed 3. Employed 4. Retired

13 A) If employed, Nature of employment

1. Technical and Professional 2. Administration and Management 3. Trained officer 4. Clerical work 5. Teacher 6. Agriculture and farming 7. Unskilled laborer 8. Others (Specify)

13 B) After diagnosis of TB, was there an impact on occupation

1. Yes 2. No

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13 B 1) If yes, what was the change?

1. Unable to attend work daily 2. Transferred to a different work place 3. Kept off work during treatment 4. Dismissed from the job 5. Other ( Specify)

14) Monthly income Amount ………………………

1. No regular income 2. Less than 3500 3. 3501- 7500 4. 7501-12,000 5. 12,001-20,000 6. Over 20,000 7. Does not like to disclose

14 A) After diagnosis of TB, was there loss of your income

1. Yes 2. No

15) Smoking habits

1. Never smoked 2. Currently smoking 3. Smoked in the past and stopped completely

15A) If currently smoking,

1 to 5 6 to 10 11 to 15 16 to 20 >20CigaretteCigarsBeediCannabisPipeOther

No of pack yearsType

No per day

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16) Do you use alcohol?

1. Occasionally 2. Regularly 3. Never

16A) If Regularly or Occasionally, type of substance

1. Arrack 2. Toddy 3. Illicit alcohol (kassippu) 4. Beer 5. Other ( Specify)

16B) Frequency of use,

16C) Do you think that taking alcohol may affect your compliance?

1. Yes 2. No

17)Do you use any other narcotic substances?

1. Yes 2. No

17 A 1) If Yes, Type of substance

1. Heroin 2. Others (Specify)

18) Have you ever been imprisoned?

1. Yes 2. No

19) With whom are you living?

1. Alone 2. Spouse/ children

Arrack Toddy illicit Beer OtherOnce in three months Once a monthOnce a week2 to 3 times per weekOnce a day2 to 3 times per dayOther

Frequency of UseSubstance Use

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3. Married child 4. Other relatives 5. Friends 6. Other ( Specify)

20) When were you initially diagnosed as having TB? ..........................................................................................................

20 A) Who/Institute confirmed your diagnosis as a TB patient

1. At a chest clinic 2. At chest hospital, Welisara

3. At another government hospital 4. By a general practitioner 5. By a consultant at a private hospital

21) When did you start taking treatment for TB (Initiation of treatment)?

21 A) As a new case (CAT 1) ……………………

21 B) Treatment after failures (CAT 2) …………………… (For treatment failures only)

22) Distance to the nearest chest clinic

1. < 10 km 2. 11-20 km 3. 21- 30 km 4. 31 - 50 km 5. 51-75 km 6. >75 km

23) Place where you have to go for DOT

1. The chest clinic 2. Government hospital 3. Central dispensary 4. Public health worker (PHM/PHI) 5. GP 6. Work place 7. Family member at home 8. With community volunteer 9. Other ( Specify)

24) Distance to the DOT center from home

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1. Less than 1 km 2. 1-5 km 3. 6 – 10 km 4. 11 – 20 km 5. 21-50 km 6. 51-75 km 7. >75 km

25) Mode of transport to DOT center

1. Walking 2. Private vehicle 3. By public transport 4. Hired vehicle 5. Other ( Specify)

26) How much time does it take?

1. Less than 15 minutes 2. 15 -30 minutes 3. 30 minutes – 1 hour 4. 1 – 2 hours 5. More than 2 hours

27) Expenditure for each visit

1. Nil 2. < 20 Rs 3. 21 – 40 Rs 4. 41 – 60 Rs 5. 60 – 100 Rs 6. > 100 Rs

28) With whom did you usually travel to the DOT center?

1. Alone 2. Spouse 3. Child 4. Relative 5. Friend 6. Other ( Specify)

29) If you were a person who went with someone, did you feel that you would have been able to go alone to the DOT center?

1. Yes 2. No

30) Was it possible for you to attend for treatment daily to the DOT center at a specific time?

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1. Possible always 2. Possible mostly 3. Difficult 4. Impossible

31) If not possible reasons? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

32) Did you take the drugs daily from the beginning after registering as a TB patient?

1. Yes 2. No

33) Did you swallow the tablets daily in front of the DOT provider at the time of visiting the DOT center?

1. Yes 2. No

34) How frequently did you visit the DOT center during intensive phase?

1. Daily 2. Weekly 3. Other (Specify)

34 A) If the answer is weekly or other, what is the reason for not visiting daily

1. DOT provider requested to take the drugs at home 2. Patient requested to take the drugs at home

35) How frequently did you visit to the DOT center during continuation phase ?

1. Daily 2. Weekly 3. Other (Specify)

35 A) If the answer is weekly or other, what is the reason for not visiting daily

1. DOT provider requested to take the drugs at home

2. Patient requested to take the drugs at home

3. After the first two months requested to come to the DOT center once a week

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36) If the answer for Q 34 A) or Q 35 A) is response No 2, what were the reasons for requesting drugs to be taken home?

1. It was easy 2. Nature of Occupation 3. Daily traveling was difficult 4. Traveling was costly 5. Difficulty in transport 6. As there was no one to go with me 7. Needed to maintain privacy 8. Due to problems at treatment place 9. Poor reception at treatment center 10. Fearing Social stigma 11. Other ( Specify)

37) What are your views regarding the need to visit DOT center daily to take drugs

1. Very good and acceptable 2. Good but not always 3. Troublesome but still does not interfere with daily activities 4. Troublesome as it interferes with daily activities 5. Waste of time 6. Important reason for defaulting

38) What are your suggestions to improve the compliance of treatment?

1. Health personnel to visit home and give the tablets daily 2. Arranging somebody to take you to the place 3. Minimize travel 4. Better reception at place of treatment 5. To have some other health personnel / volunteer 6. Closer to the home to distribute drugs 7. Other (Specify)

39) Did the treating MO explain to you that you are suffering from TB?

1. Yes 2. No

40) Did the PHI at chest clinic explain to you that you are suffering from TB?

1. Yes 2. No

41) Were your family members aware that you were suffering from TB?

1. Yes 2. No

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42) Did you have any family member living with you, who is on treatment for TB now or earlier?

1. Yes 2. No

43) Psychological impact of disease

43 A) Attitude of patient after diagnosis of TB

1. Minimally affected 2. Moderately affected 3. Greatly affected

43 B) Acceptance of patient by family

1. Good 2. Tolerable 3. Rejected

43 C) Willingness to accept DOTS at nearest health institution

1. Readily accepted 2. Accept through persuasion 3. Rejected 4. Indifferent

43 D) Written communications with patient by post from chest clinic

1. Accepted 2. Rejected 3. Indifferent

43 E) Home visits by health care personnel

1. Accepted 2. Rejected 3. Indifferent

43 F) How did you feel while you were on treatment?

1. Completely well 2. Moderately well 3. No improvement 4. No idea

44) Do you think that Anti TB drugs have many side-effects?

1. Yes

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2. No

45) If yes, how did you become aware of it? From

1. MOs at chest clinic 2. Nurses at chest clinic/ DOT center 3. Other health care personnel

4. Other patients 5. Health leaflets 6. Internet 7. Mass media

46) Did you ever come across any side effects while on TB drugs?

1. Yes 2. No

46 A 1) If yes what did you do at that time?

1. Ignored it & continued treatment 2. Sought medical advice while continuing treatment 3. Discontinued treatment & sought medical advice 4. Discontinued treatment & stayed at home 5. Other (specify)

47) Are you taking medication for any disease other than TB?

1. Yes 2. No

47 A 1) If Yes (Presence of other co-morbidity)

1. Diabetes mellitus 2. Hypertension 3. Ischemic heart disease 4. Bronchial asthma 5. COPD 6. Bronchiectasis 7. Chronic liver disease 8. Chronic renal disease 9. Cancer 10. Other ( Specify)

48) Do you think that the health care personnel around you are sensitive enough to care for TB patients?

1. Yes 2. No 3. No idea

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49) Do you think that the health care personnel around you, are trained adequately to care for TB patients

1. Yes 2. No 3. No idea

50) Were you ever stigmatized as a TB patient in public?

1. Yes 2. No

50 A 1) If Yes, by whom?

1. Family member 2. Relation 3. At work place 4. Villagers 5. Treatment center 6. Other ( Specify)

50 B) Were you able to cope with the situation?

1. Yes 2. No

50C) Was this stigmatization a problem to you at any time?

1. Yes 2. No

51) Do you think our society is educated enough to accept TB patients as any other patient without any discrimination

1. Yes 2. No

52) Do you think DOT is necessary for all our patients?

1. Yes 2. No

53) Do you think you need an observer/supervisor to take care of yourself?

1. Yes 2. No

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54) Do you think that you would have continued medicines without any interruption even without a supervisor?

1. Yes 2. No

55) Have you ever tried to hide personal information at the time of registration?

1. Yes 2. No

55A 1) If Yes why

1. Due to Social stigma 2. Fear of losing the job 3. Family problems 4. Problem with residence (may lose rented house) 5. PHI visits to the residence 6. Fear of embarrassment to you in clinic 7. Others (Specify)

56) If you had a need to go for an outstation visit for more than a day how did you take your medicine?

1. Interrupted treatment 2. Requested from DOT center to supply drugs 3. Other (Specify)

57) Do you think that you have a good understanding about the disease?

1. Yes 2. No

57 A) If yes, from where did you get that knowledge?

1. Chest Clinic 2. DOT center 3. MOH 4. Hospital 5. From leaflets 6. Television 7. News papers 8. Internet

58) Do you wish to know newer things about the disease?

1. Yes 2. No

59) Did you ever think of consulting a private sector doctor for your treatment after you were diagnosed as having TB?

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1. Yes 2. No

59 A 1 ) If yes, what made you to think like that?

1. Social stigma 2. Uncertainty about the diagnosis 3. Long waiting hours in govt. institutions 4. Convenient times in the private sector 5. To receive good quality drugs 6. Embarrassment in a TB clinic 7. Problems with government health staff 8. Others( Specify)

60) Did you ever consult a private sector doctor for your treatment?

1. Yes 2. No

60 A 1) If yes, what made you come back to the govt. sector again?

1. Private sector doctor persuaded you to go back to DOT center 2. No reasonable solution found at private sector 3. Unable to afford the expenses 4. Unavailability of drugs at private sector 5. Malpractices at private sector 6. Other ( Specify)

61) Have you ever changed your unit (DOT center)

1. Yes 2. No

61 A 1) If Yes, why

1. Social stigma 2. Change of residence 3. Problem with DOT center 4. Due to distance 5. Disability 6. Not being aware of the closest DOT center at the onset 7. Other (Specify)

62) Have you ever change your district of registration at the time of diagnosis

1. Yes 2. No

27

62 A) If Yes, why

1. Needed to return to home town 2. Loss of job 3. Change of residence 4. For occupation 5. Due to illness 6. Other ( Specify)

63) Were you hospitalized before starting on Anti TB treatment?

63 A) At the time of starting CAT 1 treatment

1. Yes 2. No

63 B) At the time of starting CAT 2 treatment (for treatment failures only)

1. Yes 2. No

64) Do you think that is it necessary to have regular chest clinic visits?

1. Yes 2. No

64 A) If Yes, why

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

64 B) If No, why

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

65) Is the family support you were getting when ill?

1. Excellent 2. Good

28

3. Satisfactory 4. Poor 5. Indifferent

66) What is your opinion on the staff courtesy?

Enumerator’s view:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Enumerator’s Number-

Chest clinicMedical officersNursing officersPHIsPharmacistsDispensersDOTS providersDOTS centereDOTS providersPHIsHospitalsMedical officersNursing officersPHIsPharmacistsDispensers

PoorNo

commentStaff Excellent Good Satisfactory

29

Annexure 5: Questionnaire No. 2 for defaulters

Serial number-

District code –

Respondent identification Number –

All Information collected at this questionnaire will be treated as strictly confidential.

Questionnaire for Evaluation of the effectiveness of the National DOTS Programme

Questionnaire NO. 2 for defaulters (Including those who have defaulted and returned for treatment as CAT 2)

1) Name of Patient …………………………………… ……………………………………………………………………………

2) District TB Number …………………………………………………………………………………………………………………

3) Diagnostic Category ………………………………………………………………………………………………………………….

30

4) MOH area …………………………………………………………………………………………………………………

5) Age (Years) ………………………………………….............................................................................................................

1. <15 Years

2. 15 – 24 Years

3. 25 – 34 Years

4. 35 – 44 Years

5. 45 – 54 Years

6. 55 – 64 Years

7. 65 – 74 Years

8. > 75 Years

6) Sex

3. Male 4. Female

7) Permanent Address ……………………………………………………………………………………………………………………………………….

8) Current place of residence

9. In a permanent residence (own or rented house) 10. In a temporary residence 11. Relative’s house 12. Boarding house 13. Hostel 14. Work place 15. Street 16. Prison

9) Ethnicity

6. Sinhalese 7. Tamil 8. Muslim 9. Burgher 10. Other ( Specify)

31

10) Level of education

8. No formal Education 9. Up to Grade 5 10. Up to Grade 10 11. Up to O/L 12. Up to A/L 13. Tertiary education 14. Other (Specify)

11) Marital status

6. Married 7. Unmarried 8. Divorced 9. Separated 10. Widowed

12) No. of children …………………………………

13) Occupation

5. Unemployed 6. Self employed 7. Employed 8. Retired

13 A) If employed, Nature of employment

9. Technical and Professional 10. Administration and Management 11. Trained officers 12. Clerical work 13. Teachers 14. Agriculture and farming 15. Unskilled laborer 16. Other (Specify)

13 B) After diagnosis of TB, was there an impact on occupation

3. Yes 4. No

32

13B 1) If yes, what was the change?

6. Unable to attend work daily 7. Transferred to a different work place 8. Kept off work during treatment 9. Dismissed from the job 10. Other (Specify)

14) Monthly income Amount ………………………

8. No regular income 9. Less than 3500 10. 3501- 7500 11. 7501-12,000 12. 12,001-20,000 13. Over 20,000 14. Does not like to disclose

14 A) After diagnosis of TB, was there loss of your income

3. Yes 4. No

15) Smoking habits

4. Never smoked 5. Currently smoking 6. Smoked in the past and stopped completely

15A) If currently smoking,

1 to 5 6 to 10 11 to 15 16 to 20 >20CigaretteCigarsBeediCannabisPipeOther

No of pack yearsType

No per day

33

16) Do you use alcohol?

4. Occasionally 5. Regularly 6. Never

16A) If Regularly or Occasionally, type of substance

6. Arrack 7. Toddy 8. Illicit alcohol (kassippu) 9. Beer 10. Other (Specify)

16B) Frequency of use,

16C) Do you think that taking alcohol may affect your compliance?

3. Yes 4. No

17) Do you use any other narcotic substances?

3. Yes 4. No

17 A 1) If Yes, Type of substance

3. Heroin 4. Other ( Specify)

18) Have you ever been imprisoned?

3. Yes 4. No

Arrack Toddy illicit Beer OtherOnce in three months Once a monthOnce a week2 to 3 times per weekOnce a day2 to 3 times per dayOther

Frequency of UseSubstance Use

34

19) With whom are you living?

7. Alone 8. Spouse/ children 9. Married child 10. Other relatives 11. Friends 12. Other ( Specify)

20) When were you initially diagnosed as having TB? ..........................................................................................................

20 A) Who/Institute confirmed your diagnosis as a TB patient

6. At a chest clinic 7. At chest hospital, Welisara 8. At another government hospital 9. By a general practitioner 10. By a consultant at a private hospital

21) When did you start taking treatment for TB (Initiation of treatment)?

21 A) As a new case (CAT 1) ………………………………

21 B) Treatment after defaulter (CAT 2) ……………………………....

22) Distance to the nearest chest clinic

7. < 10 km 8. 11-20 km 9. 21- 30 km 10. 31 – 50 km 11. 51-75 km 12. >75 km

23) Place where you have to go for DOT

10. The chest clinic 11. Government hospital 12. Central dispensary 13. Public health worker (PHM/PHI) 14. GP 15. Work place 16. Family member at home

35

17. With community volunteer 18. Other ( Specify)

24) Distance to the DOT center from home

8. Less than 1 km 9. 1-5 km 10. 6 – 10 km 11. 11 – 20 km 6. 21-50 km

7. 51-75 km

8. >75 km

25) Mode of transport to DOT center

6. Walking 7. Private vehicle 8. By public transport 9. Hired vehicle 10. Other ( Specify)

26) How much time does it take?

6. Less than 15 minutes 7. 15 -30 minutes 8. 30 minutes – 1 hour 9. 1 – 2 hours 10. More than 2 hours

27) Expenditure for each visit

7. Nil 8. < 20 Rs 9. 21 – 40 Rs 10. 41 – 60 Rs 11. 60 – 100 Rs 12. > 100 Rs

28) With whom did you usually travel to the DOTs center?

2. Alone 3. Spouse 4. Child 5. Relative 6. Friend 7. Other ( Specify)

36

29) If you were a person who went with someone, did you feel that you would have been able to go alone to the DOT center?

3. Yes 4. No

30) Was it possible for you to attend for treatment daily to the DOT center at a specific time?

5. Possible always 6. Possible mostly 7. Difficult 8. Impossible

31) If not possible reasons? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

32) When did you default taking treatment?

1. Less than 1 month after initiation of treatment

2. 1 to 2 months after initiation of treatment

3. 2 to 4 months after initiation of treatment

4. 4 to 6 months after initiation of treatment

33) When did you restart treatment (CAT 2) after defaulting? ……………………..

34) Did you swallow the tablets daily in front of DOT provider at the DOT center?

3. Yes 4. No

35) How frequently did you visit to the DOT center during intensive phase?

1. Daily

2. Weekly

3. Other (Specify)

37

35 A) If the answer is weekly or other, what is the reason for not visiting daily

3. DOT provider requested to take the drugs at home 4. Patient requested to take the drugs at home

36) How frequently did you visit to the DOT center during the continuation phase ?

4. Daily 5. Weekly 6. Other (Specify)

36 A) If the answer is weekly or other, what is the reason for not visiting daily

1. DOT provider requested to take the drugs at home

2. Patient requested to take the drugs at home

3. After the first two months requested to come to the DOT center once a week

37) If the answer for Q 35A) or Q 36A) is response No 2, what were the reasons for requesting drugs to be taken home?

12. It was easy 13. Nature of Occupation 14. Daily traveling was difficult 15. Traveling was costly 16. Difficulty in transport 17. As there was no one to go with me 18. Needed to maintain privacy 19. Due to problems at treatment place 20. Poor reception at treatment center 21. Fearing Social stigma 22. Other ( Specify)

38) What are your views regarding the need to visit DOT center daily to take drugs

7. Very good and acceptable 8. Good but not always 9. Troublesome but still does not interfere with daily activities 10. Troublesome as it interferes with daily activities 11. Waste of time 12. Important reason for defaulting

39) What are your suggestions to improve the compliance of treatment?

8. Health personnel to visit home and give the tablets daily 9. Arranging somebody to take you to the place 10. Minimize travel 11. Better reception at place of treatment 12. To have some other health personnel / volunteer

38

13. Closer to the home to distribute drugs 14. Other (Specify)

40) Did the treating MO explain to you that you are suffering from TB?

3. Yes 4. No

41) Did the PHI at chest clinic explain to you that you are suffering from TB?

3. Yes 4. No

42) Were your family members aware that you were suffering from TB?

3. Yes 4. No

43) Did you have any family member living with you, who is on treatment for TB now or earlier?

3. Yes 4. No

44) Psychological impact of disease

44 A) Attitude of patient after diagnosis of TB

4. Minimally affected 5. Moderately affected 6. Greatly affected

44 B) Acceptance of patient by family

4. Good 5. Tolerable 6. Rejected

44 C) Willingness to accept DOTS at nearest health institution

5. Readily accepted 6. Accept through persuasion 7. Rejected 4. Indifferent

44 D) Written communications with patient by post from chest clinic

4. Accepted

39

5. Rejected 3. Indifferent

44 E) Home visits by health care personnel

3. Accepted 4. Rejected 3. Indifferent

44 F) How did you feel while you were on treatment?

5. Completely well 6. Moderately well 7. No improvement 8. No idea

45) Do you think that Anti TB drugs have many side-effects?

3. Yes 4. No

46) If yes, how did you become aware of it?

8. MOs at chest clinic 9. Nurses at chest clinic/ DOT center 10. Other health care personnel 11. Other patients 12. Health leaflets 13. Internet 14. Mass media

47) Did you ever come across any side effects while on TB drugs?

3. Yes 4. No

47 A 1) If yes what did you do at that time?

6. Ignored it & continued treatment 7. Sought medical advice while continuing treatment 8. Discontinued treatment & sought medical advice 9. Discontinued treatment & stayed at home 10. Other (specify)

48) Are you taking medication for any disease other than TB?

40

3. Yes 4. No

48 A 1) If Yes (Presence of other co-morbidity)

11. Diabetes mellitus 12. Hypertension 13. Ischemic heart disease 14. Bronchial asthma 15. COPD 16. Bronchiectasis 17. Chronic liver disease 18. Chronic renal disease 19. Cancer 20. Other ( Specify)

49) What were the reasons for stopping medication?

1. Distance to DOT center 2. Income problems 3. Occupational problems 4. Stigma 5. Poor family support 6. Stopped on own because felt better 7. Because I felt that I’m being wrongly diagnosed as TB and treated 8. Decided to take treatment from somewhere else 9. Affects the treatment of other illnesses 10. Side effects are intolerable 11. Attitude and practices by health staff at DOT center 12. Attitude and practices by health staff at district chest clinic 13. Attitude and practices by health staff at other place (Specify) 14. Others ( Specify)

50) Do you think that the health care personnel around you are sensitive enough to care for TB patients?

4. Yes 5. No 6. No idea

51) Do you think that the health care personals around you, are trained adequately to care for TB patients

4. Yes 5. No 6. No idea

52) Were you ever stigmatized as a TB patient in public?

3. Yes 4. No

41

52 A 1) If Yes, by whom?

7. Family member 8. Relation 9. At work place 10. Villagers 11. Treatment center 12. Other ( Specify)

52 B) Were you able to cope with the situation?

2. Yes 3. No

52 C) Was this stigmatization a problem to you at any time?

3. Yes 4. No

53) Do you think our society is educated enough to accept TB patients as any other patient without any discrimination

2. Yes 3. No

54) Do you think DOT is necessary for all our patients?

3. Yes 4. No

55) Did you think you needed an observer/supervisor to take care of yourself to continue treatment?

3. Yes 4. No

56) Did you try to hide personal information at the time of registration?

3. Yes 4. No

56A) If Yes why

8. Due to Social stigma 9. Fear of losing the job 10. Family problems 11. Problem with residence (may lose rented house) 12. PHI visits to the residence 13. Fear of embarrassment to you in clinic

42

14. Others (Specify)

57) If you had a need to go for an outstation visit for more than a day how did you take your medicine?

4. Interrupt treatment 5. Request from DOT center to supply drugs 6. Other (Specify)

58) Do you think that you have a good understanding about the disease?

3. Yes 4. No

58 A) If yes, from where did you get that knowledge?

9. Chest Clinic 10. MOH 11. Hospital 12. DOT center 13. From leaflets 14. Television 15. News papers 16. Internet

59) Do you wish to know newer things about the disease?

3. Yes 4. No

60) Did you ever think of consulting a private sector doctor for your treatment after you were diagnosed as having TB?

3. Yes 4. No

60 A 1) If yes, what made you to think like that?

9. Social stigma 10. Uncertainty about the diagnosis 11. Long waiting hours in govt. institutions 12. Convenient times in the private sector 13. To receive good quality drugs 14. Embarrassment in a TB clinic 15. Problems with government health staff 16. Other ( Specify)

43

61) Did you ever consult a private sector doctor for your treatment?

3. Yes 4. No

61 A 1) If yes, what made you come back to the govt. sector again?

7. Private sector doctor persuaded you to go back to DOT center 8. No reasonable solution found at private sector 9. Unable to afford the expenses 10. Unavailability of drugs at private sector 11. Malpractices at private sector 12. Other ( Specify)

62) Why did you not complete the whole regimen?

1. Felt well 2. Side effects of drugs 3. Disability 4. Did not want DOT 5. Due to the reasons related to the DOT provider 6. Difficulties in collecting drug 7. Family problems 8. Occupational problems 9. Financial problems 10. Residential problems 11. Not feeling well even after starting treatment 12. Other (Specify)

63) What made you seek treatment again after defaulting? (For CAT 2)

1. Reappearance of symptoms 2. Persuasion by

a. PHI b. Any other health personnel c. Relatives & friends d. Chest clinic e. DOT provider f. Community leaders g. Work place staff h. On your own i. Legally

3. Other (Specify)

64) What are your views with regard to the prevention of defaulting of the treatment?

1. DOT at home 2. Drugs to be provided to the patient 3. Hospitalization 4. DOT at the nearest health institute

44

5. DOT by Community DOT providers 6. No views

65) Did you change your DOT center after restarting treatment (CAT 2)?

3. Yes 4. No

65 A) If Yes, why

8. Social stigma 9. Change of residence 10. Problem with DOT center 11. Due to distance 12. Disability 13. Not being aware of the closest DOT center at the onset 14. Other (Specify)

66) Did you change your district of registration at the time of diagnosis, after restarting treatment (CAT 2)?

3. Yes 4. No

66 A 1) If Yes why

7. Needed to return to home town 8. Loss of job 9. Change of residence 10. For occupation 11. Due to illness 12. Other ( Specify)

67) Were you hospitalized before starting on Anti TB treatment?

67 A) At the time of starting CAT 1 treatment

2. Yes 2. No

67 B) At the time of starting CAT 2 treatment

3. Yes 4. No

45

68) Do you think that is it necessary to have regular chest clinic visits?

1. Yes

2. No

68 A) If Yes, why

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

68 B) If No, why

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

69) Is the family support you were getting when ill?

6. Excellent 7. Good 8. Satisfactory 9. Poor 10. Indifferent

70) What is your opinion on the staff courtesy?

46

Enumerator’s view:

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Enumerator’s Number-

Chest clinicMedical officersNursing officersPHIsPharmacistsDispensersDOTS providersDOTS centereDOTS providersPHIsHospitalsMedical officersNursing officersPHIsPharmacistsDispensers

PoorNo

commentStaff Excellent Good Satisfactory

47

48

Annexure 6: Questionnaire No: 3 for the DOTS Providers

Serial number-

District code –

Respondent identification Number –

All Information collected at this questionnaire will be treated as strictly confidential.

Questionnaire for Evaluation of the effectiveness of The National DOTS Programme

Questionnaire for DOT Providers

1) Name ……………………………………………………………………………………………….

49

2) Address ……………………………………………………………………………………………….

3) Name of the DOT centre ……………………………………………………………………………

4) MOH area ……………………………………………………………………………………………….

5) DTCO area ………………………………………………………………………...................................

6) Position

A) Government health staff member

1. Medical Officer

2. Mid wife

3. Staff Nurse

4. Attendant

5. Pharmacist

6. Minor staff

7. PHI

8. Dispenser

9. Other (Specify)

B) Private health staff member

1. Medical officer

2. Mid wife

3. Staff Nurse

4. Pharmacist

5. Other (Specify)

50

C) Community leader

1. Gramasevaka

2. Priest

3. Sammurdhi Niyamaka

4. NGO

5. School principal

6. School teacher

7. Other (Specify)

D) Relative

1. Parent

2. Grand parents

3. Sibling

4. Other relation

5. Spouse

6. Other (Specify)

7) Education Qualifications

1. No formal Education 2. Up to Grade 5 3. Up to Grade 10 4. Up to O/L 5. Up to A/L 6. Tertiary education 7. Other (Specify)

8) Nature of employment 1.Technical and Professional

2. Administration and Management

3. Trained officers

4. Clerical work

51

5. Teachers

6. Agriculture and farming

7. Unskilled labourer

8. Other (Specify)

9) Are you trained for the task of being a supervisor?

1. Yes

2. No

3. Indifferent

9A 1) If Yes,

By whom

1. DTCO

2. MO chest clinic

3. PHI

4. Other (Specify)

10) Are you motivated to do this task of a supervisor?

1. Yes 2. No 3. Indifferent

11) Did you attend a DOTS modular training programme?

1. Yes 2. No

12) Is the manual on DOT available with you?

1. Yes 2. No

52

13) Do you think you have a good knowledge regarding TB?

1. Yes

2. No

14) From where did you get that knowledge?

1. DOTS training 2. Chest clinic 3. Literature 4. Mass media 5. Other ( Specify)

15) How many patients are you supervising at the moment?

1. No patients 2. 1-4 patients 3. 5-9 patients 4. 10 or above

16) Do you have a good knowledge of where your patients reside?

1. Yes

2. No

17) How long have you been involved as supervisor in the DOTS programme? (Completed years)

1. 1 year 2. 2 years 3. 3 years 4. 4 years 5. 5 years 6. More than 5 years

18) Are you familiar with the concept of DOTS?

1. Yes 2. No

53

19) Were you aware of DOTS Strategy before being a DOT supervisor?

1. Yes

2. No

20) How did you get to know about DOTS (More than one answer is possible)

1. In your undergraduate education

2. After joining the health department

3. After joining the NPTCCD

4. Other means (Media, News papers, Internet)

5. In your postgraduate training

6. In your basic training (MLT / Pharmacist /Dispenser)

7.After being recruited as a DOT provider

8. Other (specify)

21) Do your patients attend the DOT center regularly?

1. Yes 2. No 3. Not always

22) When patients interrupt treatment, what action do you take?

1. Call the patient if contact number is available 2. Send a letter to patient 3. Go to the patients place & trace him/her 4. Inform chest clinic

a. To whom i. DTCO

ii. PHI of chest clinic iii. Other (specify)

b. How i. Over the phone

ii. By letter

5. Inform MOH

54

6. Inform PHI 7. Inform the officer in charge of the DOTS center 8. Head of the institution

9. Others (specify)

23) Do you know the contact details of A) DTCO 1.Yes

2. No

B) PHI of chest clinic

1. Yes

2. No

C) Patients

1. Yes

2. No

E) Range PHI/MOH

1. Yes

2. No

D) Relatives (Specify)

1. Yes

2. No

24) What do you think are the possible reasons for irregular attendance of patients at your DOT center?

(More than one answer is possible)

55

1. Stigma

2. Transport difficulties

3. Occupational & schooling problems

4. Lack of money

5. Patients not having any one to accompany them

6. Poor awareness of the disease

7. Physical & mental disability of patients

8. Development of side effects to Anti TB treatment

9. Lack of understanding about the drugs and their action

10. Lack of confidence in treatment success

11. Problems at DOTS center

Due to over crowding

Delay in medical attention

Other (Specify)

12. Other (Specify)

25) Have you been involved in the TB control activities before being recruited as a DOTS provider?

1. Yes 2. No

26) Do you think that DOTS is better than the previous method for TB control activities

1. Yes 2. No

If the answer is Yes, go to Q 26A) & If the answer is NO, go to Q 26B)

26 A) If yes, why? (More than one answer is possible)

1. Cure rate is higher 2. Patient’s compliance is better 3. Low default rates

56

4. Can take early actions when side effects develop 5. Can take early action when patients interrupt treatment 6. Other (specify)

26 B) If No, Why? (More than one answer is possible)

1. As patients do not come regularly to the centre for various reasons 2. Difficult to convince the patients 3. Lack of cooperation by the staff 4. Difficult to supervise the intake of drugs due to high workload 5. Other (specify)

27) What are the constraints you have faced or experienced in implementation of DOTS at your center?

(More than one answer is possible)

1. Poor facilities at the DOT center 2. Difficulty in tracing the patients once they interrupted treatment 3. Inadequate & irregular Drug supply to the DOT center 4. No time due to heavy work load with other work 5. Inadequate staff cooperation 6. Poor cooperation of the patients 7. In adequate managerial support 8. Difficulties in reporting & feedback 9. Difficulties in monitoring 10. Inadequate guidance 11. Not being trained adequately for DOTS 12. Other (specify)

If the answer to above is 3,

27 A) Was any of the drugs out of stock at any time during last year

1. Yes

2. No

27 B) If yes, Name the drugs and for how long? …………………………………………

57

28) Do you think that DOT at a DOT center is necessary for all TB patients?

1. Yes

2. No

28 A) If No, to whom do you think DOT is not necessary?

1. Professionals 2. Children less than 5 years 3. School children 4. Health personnel 5. Other (specify)

29) Do the DTCO or PHI supervise the DOT center regularly?

1. Yes

2. No

29A) If yes, how often? ..............................................

30) Knowledge of DOT provider as perceived by the interviewer ( Use the annexed questions )

A) About the disease

1. Highly satisfactory 2. Satisfactory 3. Fair 4. Unsatisfactory 5. Highly Unsatisfactory

B) About DOTS

1. Highly Satisfactory 2. Satisfactory 3. Fair 4. Un satisfactory 5. Highly Unsatisfactory

C) Treatment categories & regimens

1. Highly satisfactory 2. Satisfactory

58

3. Fair 4. Un satisfactory 5. Highly Unsatisfactory

D) Awareness of side effects

1. Highly satisfactory 2. Satisfactory 3. Fair 4. Un satisfactory 5. Highly Unsatisfactory

E) Duration of treatment

1. Highly satisfactory 2. Satisfactory 3. Fair 4. Un satisfactory 5. Highly Unsatisfactory

F) Important TB messages

1. Highly satisfactory 2. Satisfactory 3. Fair 4. Un satisfactory 5. Highly Unsatisfactory

31) What are the suggestions to improve TB control activities/DOTS in your area? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Supervisors / DOT centre detail

32) Type of Institute

1. Government i. Hospital TH BH DH PU RH

59

ii. Dispensary CD CD&MH EMC (Estate medical center)

iii. Chest clinic iv. MOH office v. PHM’s office

vi. PHI’s office vii. Municipal dispensary

viii. Other govt. institute 2. Private hospital 3. Private pharmacy 4. General practitioner 5. Other Private place (Specify) 6. Work place of NGO 7. Work place of community leader

33) Is there a separate place for DOT?

1. Yes

2. No

34) Is the location of the DOT Center easy to find?

1. Yes 2. No

35) Is the Place comfortable to the patient?

1. Yes 2. No

36) Facilities available

1. Telephone 2. Chairs & other seating facilities 3. Safe water 4. Drug cupboard 5. Drug container 6. Sharp bin 7. Waste disposal bins

60

8. Instruction leaflets 9. Health education materials

Drugs

37) Are the drugs properly stored?

37A) Without exposure to sunlight

1. Yes

2. No

37C) Whether drugs are kept separately for each patient?

1. Yes

2. No

37D) Are they labeled?

1. Yes

2. No

37E) Are they placed in containers?

1. Yes

2. No

37F) Are the drugs are kept safely under lock & key?

1. Yes

2. No

37G) Is the drug supply satisfactory?

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1. Yes

2. No

37H) Were any of the drugs out of stock for more than 1 month?

1. Yes

2. No

38) Is there a DOT register?

1. Yes 2. No

38A) Is it uniform with the DOTS registers in the district?

1.Yes

2. No

39) Currently how many patients registered for DOTS? …………………….

(Check with the answer to Q 15.)

40) How many patients were given DOTS over last month? …………………….

41) How many patients were on DOTS for this year? ……………………..

42) Are treatment cards daily updated?

1. Yes 2. No

43) Are the remarks on supervision of the DOT center by the DTCO/PHI available?

1. Yes

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2. No

44) Category of the DOT providers at the working center

1. MO 2. RMO 3. Nursing officer 4. Pharmacist 5. Dispensers 6. PHM 7. PHI 8. Minor staff 9. Other ( Specify)

45) Number of DOTS providers working at the DOTS center at present? ...................................

46) Number of trained DOT providers? ........................................

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Annexure 7: District Survey Teams There were nine survey teams deployed and the surveys were carried out in the following district by the following teams headed by District DTCO.

Province District Name Designation Western Province Colombo Dr. Ruwanie Perera DTCO

Dr. Rohitha Darmasiri DTCO Mr. L.D.A.N.Kumarasinghe PHI Mr. K.U.Shantha PHI Mr.K.S.Ranasinghe PHI Mr.K.A.R.S.Weerakoon PHI

Gampaha Dr. D.Wijesighe DTCO Mr. D. Wickramarathna PHI Mr.Y. Rathnayake PHI

Kaluthara Dr. K.K.Abeyweera DTCO Mr.M. Bandara PHI Mr.S.Fernando PHI

Central Province Kandy Dr. Anoma De Silva DTCO Mr. Chanaka Hewawasam PHI Mrs. Indra Kumari PHI

Southern Province Galle Dr.Ajith Kariyawasam DTCO Mr. Gunasekara PHI

Sabaragamuwa province Ratnapura Dr. S. Mahanama DTCO Mr. Udaya Gunaratne PHI

North Western Province Kurunegala Dr. W.M.D.N.K.Wijesinghe DTCO Mr. Vajira Ratnayake PHI Mr.B.M.S.C. Balasooriya PHI

North Central Province Anuradhapura Dr. Deepthi Waidyaratna DTCO Mr. Indika Thikarathne PHI

Eastern Province Trincomalee Dr. Suresh Kumar DTCO Mr. T. Sivakumara PHI

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