title: Treatment adherence among sputum smear-positive pulmonary tuberculosis patients in mountainous areas in China.
abstract: BACKGROUND
  We carried out an investigation in five provinces in China to assess treatment adherence and identify factors associated with insufficient treatment adherence in tuberculosis (TB) patients in mountainous, rural areas of China.
  
  
  METHODS
  In each of the five provinces, all counties with > 80% mountainous area were stratified into three groups according to their gross domestic product. In each stratum, one county was randomly sampled. Study subjects were sampled from all smear positive TB cases registered in 2007 in the target counties. TB patients, village doctors, county doctors and directors of the TB prevention and control institutes were interviewed. Insufficient medication adherence was defined as taking less than 90% of anti-TB drug doses prescribed. Insufficient re-examination adherence was defined as having less than the recommended three sputum smear examinations during the treatment course.
  
  
  RESULTS
  A minority of patients took drugs under direct observation: on average 29% during the intensive phase of treatment. In total, 524 TB patients were included, of whom 49 (9.4%) took less than 90% of all doses prescribed and 92 (17.6%) did not have all sputum smear examinations, with substantial variations between the provinces. In multivariable analysis, no direct observation of treatment during the intensive phase and the presence of adverse events were associated both with insufficient medication adherence and insufficient re-examination adherence. Overall, 79% of patients were adherent both to treatment and re-examinations.
  
  
  CONCLUSIONS
  In these remote and poor areas of China, the TB control program is not fully functioning according to the guidelines. The majority of patients are not treated under direct observation, while direct observation by health care staff was associated with better adherence, both to drug therapy and re-examinations. Insufficient adherence increases the risk of unsuccessful treatment outcomes and development of drug resistance. Measures should be taken urgently in these areas to strengthen implementation of the international Stop TB strategy.
authors.affiliation: Anhui Provincial TB Research Institute, Hefei, China. ys506506@yahoo.com.cn
authors.forename: Song
authors.initials: S
authors.lastname: Yao
authors.forename: Wen-Hui
authors.initials: WH
authors.lastname: Huang
authors.forename: Susan
authors.initials: S
authors.lastname: van den Hof
authors.forename: Shu-Min
authors.initials: SM
authors.lastname: Yang
authors.forename: Xiao-Lin
authors.initials: XL
authors.lastname: Wang
authors.forename: Wei
authors.initials: W
authors.lastname: Chen
authors.forename: Xue-Hui
authors.initials: XH
authors.lastname: Fang
authors.forename: Hai-Feng
authors.initials: HF
authors.lastname: Pan
mesh_terms: D002681:China; D003430:Cross-Sectional Studies; D023801:Directly Observed Therapy / Q000706:statistics & numerical data; D024881:Drug Resistance, Bacterial / Q000187:drug effects; D004522:Educational Status; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000523:psychology; D010349:Patient Compliance / Q000523:psychology* / Q000706:statistics & numerical data; D017064:Process Assessment, Health Care; D011785:Quality Assurance, Health Care; D012424:Rural Population / Q000145:classification / Q000706:statistics & numerical data*; D055502:Secondary Prevention; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology