3 6 nursing standard august 2/vol14/no46/2000

art&s c i e n c ere s e a rc hnurs ing standard: clinical · research · education

High incidences of tuberculosis (TB) acro s s

London are posing an increasing public health

hazard, particularly to the vulnerable, socially

excluded and deprived sectors of the popula-

tion. TB rates have doubled in many London

boroughs over the past ten years (Hayward

1998). Non-adherence with therapy is the most

serious remaining problem in the control of TB

and the chief cause of relapse, drug resistance

and further transmission.

The authors were interested in investigating

issues in adherence with TB therapy and the use

of directly observed therapy, which can be a sig-

nificant burden for both the nurse and patient in

terms of time and travel (Ustianowski and Zumla

1998). This article reports on a small investiga-

tion into the current use of directly observed

therapy for patients with TB in London, under-

taken as part of a research secondment. The

investigation revealed that directly o b s e rved therapy

was a strategy that was infrequently used.

TB therapy is a regimen of daily oral medication

taken for at least six months. Adherence with

any treatment regimen is influenced by multiple

factors, including quality of communication

between professionals and patients, patient

knowledge, beliefs, culture and social contexts.

In the US, it has been well documented that at

least 35 per cent of patients – re g a rdless of socio-

economic background, culture, or educational

achievement – ignore their physician’s recom-

mendations on TB therapy (Sbarbaro 1980). A

UK study (Ormerod and Bentley 1997) showed

that 20 per cent of patients did not complete a

recommended regimen and nearly 10 per cent

w e re re c o rded as doubtful adherers. Many studies

have found that alcoholism, drug addition,

homelessness and mental illness correlate signif-

icantly with poor adherence (Evans 1995,

Sumartojo 1993, Weis et al 1994).

Directly observed therapy requires that over a

six-month period, every dose of the drugs be

administered by a supervisor. In the UK, this

needs to be established and monitored by the

TB nurses.

In New York City, directly observed therapy

was implemented in 1992 as part of a control

programme in the face of rising cases and out-

breaks of multiple drug-resistant TB with fatality

rates above 80 per cent. Multiple drug-resistant

TB is defined as resistance to both the mainline

drugs, rifampicin and isoniazid, with or without

resistance to any other anti-TB drug.

Just two years later, the city announced a sub-

stantial decrease in new cases. Epidemiological

p a t t e rns strongly suggest that the decre a s e

resulted primarily because of better rates of

completion of treatment and expanded use of

directly observed therapy. The number of staff in

the TB control programmes increased from 144

to more than 600 and the budget increased fro m

$4 million to more than $40 million between

Promoting adherence

Understanding the issues in non-adherence

I n t r o d u c t i o n

Ann Goodburn RGN, RHV, is TB

Nurse Specialist, Camden and

Islington Community NHS Trust.

Vari Drennan MSc, RGN, RHV,

BSc, is Senior Lecturer in Primary

Care Nursing, Department of

Primary Care and Population

Sciences, Royal Free and UCL

Medical School, London.

The use of dire c t l yo b s e rved therapy in TB: a brief pan-London surv e yGoodburn A, Drennan V (2000) The use of directly observed therapy in TB: a brief p a n - London surv e y. Nursing Standard. 14, 46, 36-38. Date of acceptance: June 27 2000.

Aim The objective of this study was to

investigate issues regarding adherence with

tuberculosis therapy and the use of directly

observed therapy.

Method A small-scale survey of TB nurse

specialists at chest clinics in London was

carried out to determine the current use of

directly observed therapy for patients with

tuberculosis in London.

Results Responses to this survey indicate

that directly observed therapy is currently

used in less than half the available services

in London. Many of the specialist TB nurses

indicated that lack of resources and time

were drawbacks to implementing directly

observed therapy.

Conclusion Directly observed therapy was

found to be a strategy that was infre q u e n t l y

used as a last measure for those people

who were previous non-adherers.

A b s t r a c t

■ Infection contro l

■ Tu b e rc u l o s i s

These key words are based

on the subject headings from

the British Nursing Index. This

article has been subject to

double-blind review.

key words

1988 and 1994. Outreach workers travelled to

patients’ homes and workplaces, as well as to

street corners, parks, and even ‘crack dens’ in

abandoned buildings, to ensure that patients

were appropriately treated.

By the end of 1994, more than 1,200 patients

were receiving directly observed therapy, as

compared with fewer than 50 in 1983, giving an

indication of the scale of investment in the pro-

gramme (Frieden et al 1995). Failure to take

notice of increasing rates of TB and ensure

adequate TB control now could result in major

p roblems and expenditure in the future

( H a y w a rd 1998).

In the UK, where TB is treated by experienced

physicians working closely with TB health visitors

or nurses, directly observed therapy is recom-

mended for patients who are unlikely to adhere

to treatment. These include patients who are

homeless, patients who abuse alcohol or drugs,

drifters, those who are seriously mentally ill,

patients with multiple drug resistance, and those

with a history of non-adherence with anti-TB

medication, either in the past or documented

during treatment monitoring (JTCBTS 1998). It is

also recommended that directly observed therapy

should be considered for new immigrants and

refugees (JTCBTS 1998).

In the UK, Volmink and Garner (1997)

reviewed five trials of strategies to improve

adherence. Interventions examined were:

■ Reminder letters.

■ M o n e t a ry incentives and help from peer

group through community health workers.

■ Health education.

■ Monetary incentives and health education.

■ Intensive supervision by staff.

All of the interventions tested improved adher-

ence. Monetary incentives were the most eff e c t i v e

in promoting adherence (£3 and bus tokens for

a clinic appointment).

Analyses in the US suggest that both selective

and universal directly observed therapy policies

are cost effective when compared with conven-

tional therapy (JTCBTS 1998). There is a need for

research that attempts to define the different

methods used to deliver directly observed therapy

and to determine which are cost effective as

well as acceptable to patients (Sumart o j o

1993). In the UK there have been no published

studies re g a rding the extent to which dire c t l y

o b s e rved therapy is used, the associated costs

or its eff e c t i v e n e s s .

This small survey was undertaken to gain greater

understanding of the use of d i rectly observ e d

t h e r a p y in TB services across London and of how

the TB specialist nurses working in the s e rv i c e s

viewed d i rectly observed therapy. The pan-London

perspective was considered important, because

mobility rates for many vulnerable groups are

high across borough and health authority

boundaries. Questionnaires were distributed to

TB nurse specialists at the 25 listed chest clinics

across London.

The TB specialist nurses reported that d i re c t l y

o b s e rved therapy was being offered by 12 of the

20 services that responded. At these 12 clinics,

the number of patients on directly observed

therapy at the time ranged from three to 14,

with between three and eight the most frequent

number.

The nurses reported on the characteristics of

the patients to whom d i rectly observed therapy

was off e red (Table 1). A history of non-adhere n c e

was the most frequently reported characteristic

in this survey for placing a patient on d i re c t l y

o b s e rved therapy.

Nine of the 12 services had a written protocol.

Five of these were identical – four were from dif-

ferent trusts in the same health authority area.

All indicated that the TB nurse specialists super-

vised directly observed therapy in clinics, but

referred to the possibility of other community

nurses and key workers supervising therapy in

community settings.

The nurses were asked to offer their views on

the benefits and problems of using directly

observed therapy . Most of the respondents (16)

said the benefit of directly observed therapy was

the ability to ensure that a patient has taken his

or her medication.

Five nurses specifically mentioned its role in the

prevention of drug-resistant tuberculosis. Five

also re f e rred to the opportunities dire c t l y

observed therapy gave to support the patient

regarding other issues, such as housing and

Views on using directly observed therapy

Protocols for directly observed therapy

Re s u l t s

The surv e y

august 2/vol14/no46/2000 nursing standard 37

art&s c i e n c ere s e a rc hnursing standard: clinica l · research · education

History of non-adherence on previous treatment 11

Substance abuse 5

Psychiatric disorder 5

Chaotic lifestyle 4

Unable to supervise own therapy 4

or confused by drug regimen

Homeless 3

Drug resistance 3

Table 1. Characteristics of patients given directly observed therapy

social problems, and for health promotion.

Half the nurses said the drawback of directly

observed therapy is that is too time-consuming

for staff and/or patients. Three respondents said

the lack of resources in the service to undertake

directly observed therapy was a clear drawback.

Six respondents commented on negative effects

for the patient, such as creating mistru s t

between the nurse and patient.

Six nurses said that directly observed therapy

created problems for patients because they had

to visit the clinic frequently. Two respondents

were concerned by the likelihood of increased

side effects for the patient on directly observed

therapy when the usual daily medication was

given in larger doses three times a week.

This survey might indicate that directly observed

therapy is currently used in less than half the

services in London. This would support Evans’

(1995) view that there is a lack of coherence or

agreement in the strategy for managing TB in

the UK. Total notifications of people with TB in

London in 1997 were 2,429 (Hayward 1998).

This survey indicates that a small percentage of

these (67 people) are having their therapy

directly observed to ensure it is completed,

while between 20 per cent and 35 per cent

might be having difficulties completing therapy.

Another reason why patients do not adhere to

therapy is that they simply forget.

The patients placed on directly observed therapy

a re those at the extreme end of non-adherence. It

is being used as a last measure for people who

w e re previous non-adherers. However, a number

of the nurses recognise the potentially negative

impact of such a policy for both the patients

and their clinical relationship.

M o re than half of the specialist TB nurses (11)

cited lack of re s o u rces and time as a drawback

to implementing directly observed therapy. It is

well documented that an efficient dire c t l y

o b s e rved therapy programme usually re q u i re s

a substantial financial and technical invest-

ment in TB programmes (Garner and Vo l m i n k

1997). When patients do not comply with

treatment, the responsibility must be in part due

to inadequate programmes (Sumartojo 1993).

Two of the services that responded to the survey

cover the cost of fares for patients who have

their therapy observed. Research has shown

m o n e t a ry incentives, including transport costs, to

be highly effective in pro m o t ing compliance

(Sumartojo 1993, Volmink and Garner 1997).

The protocols demonstrated many similarities,

but also a number of differences. The services

might be assisted by a pan-London template

protocol, amended in the light of local issues.

This might also provide a more unified approach

in supporting those people who move fre q u e n t l y

w i t hin London.

The consequences of patients developing dru g -

resistant bacilli are treatment failure, the added

expense and side effects of treating multiple

drug-resistant TB, and the real possibility of

transmitting multiple dru g - resistant TB to others.

Therapy is re q u i red for a minimum of six months

and parallels can be drawn with the need for

total adherence to antire t roviral therapy for HIV

patients.

TB is a growing problem in London, just as it

was in New York City ten years ago, when the

neglect of TB control led to rapidly escalating

rates of disease, extremely high levels of multiple

drug-resistant TB and the need for massive rein-

vestment to restore control.

In London, available resources for TB preven-

tion and control are focused around the initial

acute care and management of the disease.

There is a legal requirement for notification of

initiation of treatment, but rates of completion

and outcomes of treatment are not routinely

recorded and are unknown. Directly observed

therapy is not widely used in London, is mainly

clinic based and the British Thoracic Society

guidelines (JTCBTS 1998) are far from being

addressed.

Community nurses, care workers, adhere n c e

buddies and family members could have an

i m p o rtant role to play in encouraging adhere n c e

with treatment. There is a range of questions to

be explored re g a rding the variety of possible

methods for helping patients with TB therapy in

the UK

C o n c l u s i o n

D i s c u s s i o n

3 8 nursing standard august 2/vol14/no46/2000

art&s c i e n c ere s e a rc hnursing standard: clinical · research · education

■ To ensure greater control over increasingTB rates, directly observed therapy couldbe introduced more widely

■ Nurses involved in treating patients withTB might have an important role inencouraging adherence with treatment

Implications for practice

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Frieden TR et al (1995) Tuberculosis inNew York City: turning the tide. NewEngland Journal of Medicine. 333, 4,229-233.

Garner P, Volmink J (1997) Directlyobserved therapy. Lancet. 350, 666-667.

Hayward A (1998) Tuberculosis Control inLondon: The Need For Change .Report for the Thames RegionalDirectors of Public Health, NHSExecutive.

Joint Tuberculosis Committee of theBritish Thoracic Society (1998) BritishThoracic Society Guidelines. Thorax.53, 7, 536-548.

Ormerod LP, Bentley C (1997) Themanagement of pulmonarytuberculosis notified in England andWales in 1993. Journal of the RoyalCollege of Physicians. 31, 6, 662-665.

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