Tuberculosis (TB) management remains a major challenge despite the implementation of Directly Observed Treatment Short-Course (DOTS). Some of the challenges include defaulting treatment, low TB cure rates and relapse after patients had been treated under DOTS.
This study explored and described experiences of patients having TB regarding the use of DOTS in Doctor Ruth Segomotsi Mompati District of North West Province, South Africa. The study describes and recommends support required by patients having TB who are using DOTS.
A qualitative, exploratory, descriptive and contextual design was used. The population consisted of all patients having TB under DOTS who had taken treatment for 2 months and more in one of the community health centres in Doctor Ruth Segomotsi Mompati District. Purposive sampling technique was applied to select participants receiving DOTS service. In-depth unstructured individual interviews were conducted, and data saturation occurred after having interviewed 15 participants. Ethical considerations were ensured throughout the study, and data were analysed using Tesch’s method of coding and analysis.
Two themes emerged from data and these are discussed as concerns related to ineffective use of DOTS and lack of resources as contributory factor to ineffective use of DOTS. Among other categories, poor nurse–patient relationships and difficulties in accessing the community health centre emerged as consistent themes related to default and inconsistent use of DOTS.
Ineffective use of DOTS contributed to TB treatment default and low cure rate. Therefore, recommendations focused on strengthening effective use of DOTS for the management of TB.
Tuberculosis (TB) remains a major global health problem. The literature revealed an estimated 8.6 million people have developed TB and 1.3 million have died from the disease (World Health Organization
The study conducted in the United States by Glassman and Fan (
The report revealed that patients having TB who were registered for DOTS programmes in Russia and the Philippines had better treatment outcomes than other countries in Sub-Saharan Africa. The cure rates in Russia and Philippines increased annually, and the target was reached in 2003 until 2007 (WHO
Even though the benefits of using DOTS programmes in TB management have been reported, challenges regarding TB management and DOTS are also raised, especially in the developing countries. The study conducted in Ethiopia on DOTS reported that low TB cure rate was associated with poor observation of patients during the course of treatment and poor patient treatment compliance (Sisay
South Africa is identified as one of the 22 high-burden countries that contribute approximately 80% of the total global burden of TB cases as reported by the TB strategic plan for South Africa (
The study conducted in Moses Kotane Hospital in the North West Province focused on nurses’ views regarding the discharge plan of patients having TB (Motsomane & Peu
Despite the implementation of DOTS, the anecdotal evidence revealed challenges regarding TB management in Doctor Ruth Segomotsi Mompati of North West Province. This was observed by the researcher when she was working as a professional nurse in the primary healthcare facilities in Doctor Ruth Segomotsi Mompati District. The researcher observed patients defaulting TB treatment and low TB cure rate and relapse after patients had been treated under DOTS. The patients in whom TB relapsed were at risk of developing Multiple Drug Resistant and Extreme Drug Resistant TB. In addition, there is limited information regarding experiences of TB using DOTS in the North West Province. Thus, the following are the research questions of this study: What are the experiences of patients having TB regarding the use of DOTS and what support do they expect in order to enhance the efficient use of the DOTS programme?
The purpose of this study was to describe and explore the experiences of patients having TB regarding the use of the DOTS programme in Doctor Ruth Segomotsi Mompati District. The study also recommended the kind of support needed for patients using DOTS in this district.
The objectives of this study were to:
Explore and describe the experiences of patients having TB using DOTS, and
Describe the support required by patients having TB using DOTS.
According to Polit and Beck (
This study was guided by the assumptions in Watson’s theory of human caring developed in 1975 (Sisca
A qualitative, descriptive, exploratory and contextual research design (Brink, van der Walt & van Rensburg
The population of this study comprised patients having TB on DOTS at one of the community health centres in Kagisano and Molopo Sub-district in Doctor Ruth Segomotsi Mompati District of North West Province, South Africa.
Purposive sampling (Brink
This study took place during October 2011. Data were collected by means of unstructured in-depth individual interviews (Brink
The study used eight steps of Tesch’s method (Creswell
Ethical clearance was obtained from the Ethics Committee of North-West University (NWU 00249 11 A9) and permission was granted by the North West Province Department of Health. Furthermore, permission to conduct the research was requested in writing to the manager of the district where the study took place. Informed consent was obtained from the participants in order to allow them to decide voluntarily whether to participate in the study. This was achieved by explaining the research topic, aim and objectives of the study and the purpose of the study. It was further explained to the participants that codes instead of names would appear on the interview documents to ensure anonymity. Thereafter, voluntary participation was ensured by patients having TB signing an informed consent form (Brink
The model proposed by Lincoln and Guba (1981) was used to ensure trustworthiness of the findings and criteria used were the truth value, applicability, consistency and neutrality. The strategies used to validate these four criteria were credibility, transferability, dependability and confirmability (Krefting
Two broad themes, categories and sub-categories emerged from data.
Summary of findings.
Themes | Categories | Sub-categories |
---|---|---|
Ineffective use of DOTS | Lack of communication among different stakeholders | Lack of communication between hospital doctors and clinic nurses |
Poor nurse–patient relationship | Quarrels |
|
Lack of health education for patients using DOTS | Lack of knowledge of TB treatment phases and side effects |
|
Lack of supervision | Lack of supervision at the clinic |
|
Lack of resources to implement |
Lack of food provisions to meet basic needs | Lack of food supplements |
The 15 participants expressed their concerns related to ineffective use of DOTS. The categories that emerged from this theme were (1) lack of communication among different stakeholders, (2) poor nurse–patient relationship, (3) lack of health education for patients using DOTS and (4) lack of supervision. The categories are subsequently described in detail.
The participants experienced some lack of communication between hospital doctors and clinic nurses as well as between clinic nurses and patients on DOTS. This is discussed as follows:
Nurses at the clinic wanted patients to be given a pink referral form but the doctors provided patients with an ordinary letter or a white or green card as a way of communication. It was found that nurses became angry with patients who were not given the correct referral documents by the doctors from the hospital. One of the participants said:
‘My first day on arrival for registration at the clinic from… from the hospital where I was… was diagnosed TB, I experienced some problems. I was given a letter by the doctor for me to give it to the sisters at clinic. I was sent back to hospital because the nurses said that I am supposed to come with the TB letter and at the hospital I was sent back again and the doctor said… said they… they should put me in a clinic list. The nurses again refused at TB … at TB clinic. I went back again to the hospital, then the doctor and nurses spoke telephonically, I was then was put on the clinic list.… I went back to hospital the doctor wrote another letter for me again and after that they did send [
When referring a patient having TB to another health facility, a TB ‘transfer and move’ form should be duly completed and filled in triplicate with the correct advisory information and a pink copy must be given to the patient (National Tuberculosis Control Programme
During data collection, participants indicated that communication in their day-to-day visits to the clinic was lacking. One of the 15 participants said:
‘When I arrive at the clinic for daily treatment, nurses do not ask you any questions … you just enter … enter in the TB room to take tablet, you take your treatment and after drinking … the nurses make a tick in the green card provided to show that you came for the tablets and after that you leave, and at times they don’t tick, if they have not ticked when getting home I make a tick.’ (Participant 7, Female, Age 23, Unemployed)
The same participant said: [Silent] ‘nurses should be friendly and… be free to TB patients so that patients should take treatment as required’.
In this study, most of the participants reported that when they arrived at the clinic, they simply take the tablets placed on the table and the nurses would tick their cards, and they also noted that occasionally the ticking was not done. These findings suggest that patients took treatment at the clinic on a daily basis without the anticipated supervision from health professionals. In a study by Zvavamwe and Ehlers (
A poor nurse–patient relationship emerged in the form of quarrels and deliberate hurt of patients’ feelings.
In this study, some participants reported quarrels and one said:
‘[
The study revealed a quarrel with a patient during administration of injection. Another participant said:
‘The nurses should learn to talk nicely with a person, that’s my request [
This shows that patients might default treatment when they are not motivated by healthcare providers.
Njozing, Edin and Hurtig (
The participants expressed hurt feelings and felt unhappy and unwilling to turn up for treatment the next day. One participant had this to say:
‘When I was sick and unable to walk… I missed treatment as I could not travel to the clinic and during that time I requested my kids to go to the clinic to ask for my treatment and that day my kids were not given tablets. Instead, they sent a home-based care giver to come and convince me to go to the clinic. Upon my arrival at the clinic that day it was not nice [
Good therapeutic alliance is underpinned by trust, empathy and positive regard for patients under the monitoring eye of the hospital and clinic staff (Tadesse
This category is discussed as lack of knowledge of TB treatment phases by patients using DOTS and lack of knowledge of the side effects of Rifafour medication, which caused late reporting of side effects.
Lack of knowledge of TB treatment phases was expressed by the participants and one had this to say:
‘[
Another participant said ‘nurses who are responsible for TB patients must teach us more about TB; they should explain to us more about TB, they can teach us more and it can be better’.
The study conducted by Dolma, Adhikari, Mohapatra and Mahanta (
Five participants suffered side effects of treatment and one had this to say:
‘By the time I started to take treatment I was having a problem of constant dizziness, I still remember that I told the nurse but…but… that day I explained to the sisters… that day after taking treatment at the clinic I explained that it is of no use because on my way home I will vomit and I requested to be given tablets to take it [
Rifafour e-200 is a combination drug for treating TB and one of the adverse side effects of this drug is nausea and vomiting because it has a metallic taste (South African Medicines Formulary
The need for relevant health talks with patients having TB also emerged, as one of the participants said:
‘Every Thursday we get into a meeting they teach, they are talking about the leading province that experience problems of TB. During last week they also said that this clinic [
The participants revealed nurses giving health talks that were not clear and relevant enough to address patients’ problems concerning TB and DOTS. This demonstrates ineffective use of DOTS and a need for relevant and clear health talks with patients having TB. Watson’s theory of human caring explains that the teaching role is critical in a caring relationship. It was further revealed that caring depends on the nurses’ ability to accurately assess patients’ understanding (Sisca
During discussions, it was found that supervision of patients was lacking while they took treatment. This is subsequently discussed as lack of supervision at the clinic and at home.
There was no direct supervision of patients who were taking the tablets daily at the clinic and one of the participants had this to say:
‘When we arrive there we will get a lot of tablets placed on the table. The nurses do not give us tablets they just tell us that we should take and drink tablets for ourselves without them checking whether we are taking the right treatment or not, which is not the right thing to do, because other patients just drink without knowing whether this is the right or wrong tablet to take. Entlik… … [
The same participant said:
‘If maybe someone could talk to the nurses so that they should observe patients when coming to the clinic to find out whether they are taking treatment appropriately. The nurses must be the ones who are giving patients treatment, so that when talking to someone about being cured from TB, one must say that with confidence knowing that I was given treatment by a nurse not by myself taking it from the table.’ (Participant 4, Male, Age 26, Unemployed)
This particular patient reported that different tablets were placed on the table and it was not easy for patients to pick up the correct name and strength of a prescribed drug because some patients were illiterate. The findings of this study suggest that patients having TB were exposed to non-compliance to TB treatment because of a lack of actual observation and giving patients appropriate TB drugs at the clinic. Therefore, DOTS was used ineffectively. Dooley
It was found that all patients who were using DOTS at the health centre were given treatment to take at their homes for 3 days. The patients visited the clinic from Monday to Thursday and thereafter were supplied with 3 days’ treatment.
One participant said:
‘Neeh… the nurses supply me with treatment of Friday [
The findings of this study revealed no direct observation and supervision of patients when taking treatment at home. These suggest that the patients having TB were at risk of defaulting treatment because of lack of supervision. Motsomane and Peu (
According to what was said by the participants, it was obvious that lack of resources contributed to ineffective use of DOTS. The categories that emerged from this theme are discussed as (1) lack of provision to meet the basic needs of patients having TB.
The participants specified the basic challenges they encountered, which also contributed to ineffective use of DOTS. This is discussed as lack of food supplements and difficulties in accessing the clinic.
During data collection, the participants reported that lack of food contributed to ineffective use of DOTS.
A participant said: ‘I feel dizziness after taking treatment because at times I go to clinic without breakfast taken … and these tablets increases one’s appetite and you will always feel hungry’.
Another one said:
‘We … you get two phuzamandla, you get two and at times one… you eat that for two days or three days then it get finished [
In a study conducted by Govender and Mash (
During the interviews, it was discovered that patients were walking long distances to the health centre.
One of the participants stated:
‘I had swelling of my legs as well as abdomen and [was] unable to walk for a long distance but I endured… [
Another participant identified difficulty in accessing the clinic and said: ‘I am accompanied by my uncle with a donkey cart because I am unable; our place is far from the clinic. I am suffering painful legs (sic). I am only using a donkey cart, yes’.
This study clearly identified that sick patients having TB walked long distances. Some of the participants explained that they used donkey carts for accessing health facilities. Those who were staying on nearby farms reported that treatment was defaulted because of lack of money to get to the clinic. These observations confirm the findings by Govender and Mash (
Some of the patients who were interested and volunteered to participate were recent admissions of less than 2 months. The state of illness of other patients could not allow them to withstand interviews. Therefore, the researcher could not interview patients having TB on DOTS who had only been on the DOTS for a short time as well as those who appeared very ill but had been on DOTS for longer. The study was conducted in one Health Care Centre; thus, findings from this study could not be generalised. The study could be replicated in another setting.
Based on the findings of this study, the following are the recommendations for effective use of DOTS:
There should be effective and quality communication between doctors and nurses to improve the support and continuity of care to patients having TB. Complete filling of appropriate referral documents stated in TB guidelines should be complied with. The communication should be continued telephonically when necessary.
A contact person should be identified immediately so that the involvement of a treatment supporter is initiated at an early stage of treatment. Nurses at the clinic level should involve family members, and the roles of family members with regard DOTS should be clarified. The possibilities of developing side effects from DOTS drugs should be addressed on the first contact with the patient and family member(s). Community volunteers should be involved by identifying patients who will need their support. The mobile clinic staff should be involved in providing treatment to patients who stay at a distance from the clinic. The facility manager, TB coordinator and Assistant Director for Community Health Services should provide consistent support to the clinic staff for effective use of DOTS.
Nurses and doctors should receive regular training regarding the management of TB at the hospital to clinic and community level. Documents related to referral from the hospital to the clinic should be included in the training to ensure that everyone who will continue with care and support of the patient is informed on how to proceed. Such training should include the implementation of DOTS. Home-based caregivers and other community workers should be included in these workshops. In-service training must be done on a regular basis for improving adherence to TB guidelines. Nurses should be trained on communication skills to improve on nurse–patient relationship.
The patients having TB on DOTS should be encouraged to use a suggestion and complaints box. This could expose them to an environment where they can express their concerns without fear. The complaints in the suggestion box should be addressed on a monthly basis.
Regular and relevant health education should be given to patients having TB, health talks should be specific and the topics should address DOTS and the importance thereof. The health education plan should also include TB treatment phases according to regimens, protocol to be followed when changing treatment dosages for patients because some participants expressed surprise during the change of treatment, especially when these patients had minor and major side effects from previous treatment.
The principles for administration of medicines should be reinforced. Supervision at the clinic should be strengthened and TB medication should be kept under lock and key, meaning that the dispensing point should be a medicine trolley or tray not an open space table. Professional nurses should be the ones to dispense TB drugs.
The patients having TB who are staying further than 2 km away have to be attached to the nearest community volunteer. The family members of such patients should be actively involved in the support of patients having TB on DOTS.
The curriculum for basic nurse training for all levels should include management of all categories of patients having TB. This could ensure that nurses at the beginning level acquire knowledge of TB and effective use of DOTS.
This study recommends research that will review the national social grants policy. The policy could make provision for disadvantaged patients having TB to receive social grants at an early phase of treatment. This could alleviate situations of patients defaulting treatment because of lack of food and hunger.
It is important for further research to be conducted that focuses on the views of nurses who are caring for patients having TB, so as to obtain a broader view of challenges facing the DOTS programme. Research exploring support of nurses caring for patients having TB is also recommended. Equally, research on patient satisfaction with the service in rural areas needs to be conducted so as to obtain a broader view on challenges facing the health services.
The qualitative exploratory and descriptive study conducted on patients having TB revealed that DOTS was used ineffectively in one of the primary healthcare facilities in the North West Province. The study revealed ineffective use of DOTS which occurred because of a lack of communication between healthcare providers at the hospital and the community health centre. The nurse-patient relationship was also a very serious concern as the patients experienced quarrels and hurt feelings. The standard of sharing information to patients having TB was found to be of low quality as irrelevant topics were discussed with patients. Nurses who were not informed about the protocol and guidelines of TB management were posing a huge challenge in the control of TB. The findings of this study revealed nursing care standards that were highly compromised as the rules of giving treatment to patients were not adhered to. By allowing patients to take treatment on their own without actually giving it to them at the health facility is a medico-legal hazard because the medicines should be handled by a trained health professional. In this study, a large number of tablets were placed on the table for patients to take. Therefore, patients did self-administration of tablets which were also not kept safe. Furthermore, very ill patients having TB were exposed to the risk of developing serious complications and possible death during their daily visits to the clinic. This indicates poor nursing administration, which caused ineffective use of DOTS strategy. This further suggests poor supervision and lack of support to nursing personnel dealing with TB. Based on the findings of this study, it was evident that ineffective use of DOTS contributed to low TB cure rate, patients defaulting treatment and relapse. The recommendations focused on strengthening the effective use of DOTS. Another research that may focus on nurses caring for patients having TB in rural primary healthcare facilities of the North West Province could be necessary to obtain a broader picture of the use of DOTS.
The authors acknowledge support given by the North-West University, Nursing Department, North-West Department of Health and the participants in this study.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
M.G.S. was the main researcher and the author who initiated the writing and finalisation of the manuscript. M.D-M. was the main supervisor during research and writing of the manuscript. G.M.M. was the co-supervisor.