title: Determinants of Default from Tuberculosis Treatment among Patients with Drug-Susceptible Tuberculosis in Karachi, Pakistan: A Mixed Methods Study.
abstract: OBJECTIVE
  Non-adherence to tuberculosis therapy can lead to drug resistance, prolonged infectiousness, and death; therefore, understanding what causes treatment default is important. Pakistan has one of the highest burdens of tuberculosis in the world, yet there have been no qualitative studies in Pakistan that have specifically examined why default occurs. We conducted a mixed methods study at a tuberculosis clinic in Karachi to understand why patients with drug-susceptible tuberculosis default from treatment, and to identify factors associated with default. Patients attending this clinic pick up medications weekly and undergo family-supported directly observed therapy.
  
  
  METHODS
  In-depth interviews were administered to 21 patients who had defaulted. We also compared patients who defaulted with those who were cured, had completed, or had failed treatment in 2013.
  
  
  RESULTS
  Qualitative analyses showed the most common reasons for default were the financial burden of treatment, and medication side effects and beliefs. The influence of finances on other causes of default was also prominent, as was concern about the effect of treatment on family members. In quantitative analysis, of 2120 patients, 301 (14.2%) defaulted. Univariate analysis found that male gender (OR: 1.34, 95% CI: 1.04-1.71), being 35-59 years of age (OR: 1.54, 95% CI: 1.14-2.08), or being 60 years of age or older (OR: 1.84, 95% CI: 1.17-2.88) were associated with default. After adjusting for gender, disease site, and patient category, being 35-59 years of age (aOR: 1.49, 95% CI: 1.10-2.03) or 60 years of age or older (aOR: 1.76, 95% CI: 1.12-2.77) were associated with default.
  
  
  CONCLUSIONS
  In multivariate analysis age was the only variable associated with default. This lack of identifiable risk factors and our qualitative findings imply that default is complex and often due to extrinsic and medication-related factors. More tolerable medications, improved side effect management, and innovative cost-reduction measures are needed to reduce default from tuberculosis treatment.
authors.affiliation: Jay Weiss Institute for Health Equity at Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, United States of America.|Department of Internal Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Natasha
authors.initials: N
authors.lastname: Chida
authors.affiliation: Interactive Research and Development, Karachi, Sindh, Pakistan.
authors.forename: Zara
authors.initials: Z
authors.lastname: Ansari
authors.affiliation: Indus Hospital Research Center, Indus Hospital, Karachi, Sindh, Pakistan.
authors.forename: Hamidah
authors.initials: H
authors.lastname: Hussain
authors.affiliation: Indus Hospital Research Center, Indus Hospital, Karachi, Sindh, Pakistan.
authors.forename: Maria
authors.initials: M
authors.lastname: Jaswal
authors.affiliation: Jay Weiss Institute for Health Equity at Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, United States of America.
authors.forename: Stephen
authors.initials: S
authors.lastname: Symes
authors.affiliation: Interactive Research and Development, Karachi, Sindh, Pakistan.|Indus Hospital Research Center, Indus Hospital, Karachi, Sindh, Pakistan.
authors.forename: Aamir J
authors.initials: AJ
authors.lastname: Khan
authors.affiliation: Interactive Research and Development, Karachi, Sindh, Pakistan.
authors.forename: Shama
authors.initials: S
authors.lastname: Mohammed
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000995:Antitubercular Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D023801:Directly Observed Therapy / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010154:Pakistan; D010349:Patient Compliance / Q000523:psychology / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure; D014376:Tuberculosis / Q000188:drug therapy*
chemical_list: D000995:Antitubercular Agents