FOREIGN STUDY MA Feizi (2008) stated that tuberculosis (TB) is a major contributor to the global burden of disease and

has received considerable attention in recent years, particularly in low and middleincome countries where it is closely associated with HIV/AIDS. The number of new cases arising each year is still increasing globally and in the WHO regions of Africa, the Eastern Mediterranean and South-East Asia. WHO has declared that TB is a global emergency, because TB is out of control in many parts of world.3 Although implementation of the Directly Observed Treatment (DOTS) strategy is the foundation for proper tuberculosis control, basic DOTS implementation may not be enough to reach the targets. Instead, evidence from several countries indicates that, although cure rates are approaching the global target, the case detection target may not be met, even with 100 % DOTS implementation in designated public facilities.3 Thus, TB control must be critically examined to foster higher performance. ln the context of an expanded framework for TB control, there are four strategic interventions through which cure and case detection rates may be significantly improved: 1) wider involvement of community workers, 2) engagement of private practitioners, 3) proper management of drug-resistant tuberculosis, and 4) efforts focused on controlling tuberculosis and human immunodeficiency virus.Since 1990, the Global Tuberculosis program (GTB) has promoted the revision of national TB programs to strengthen the focus on short-course DOTS and close monitoring of treatment outcomes.5 The aim of this study was to assess factors responsible for compliance of medical treatment among TB patients referred to Urmia University of Medical Sciences urban and rural health centers. According to WHO, reduction of TB incidence, prevalence and deaths could be achieved in

most parts of the world by 2015, but the challenge will be greatest in developing countries.6 It has been estimated that near 40 % of these patients stop their medical treatment before finishing the period of their treatment. Services for TB care should identify and address factors that may make patients interrupt or stop treatment. Supervised treatment, which may have to include DOT, helps patients to take their drugs regularly and complete treatment, thus achieving cure and preventing the development of drug resistance. Supervision must be carried out in a context-specific and patient-sensitive manner, and is meant to ensure adherence on the part both of providers (in giving proper care and support) and of patients (in taking regular treatment). Depending on the local conditions, supervision may be undertaken at a health facility, in the workplace, in the community or at home. It should be provided by a treatment partner or treatment supporter who is acceptable to the patient and is trained and supervised by health services. Patient and peer support groups can help to promote adherence to treatment. Selected patient groups, for example prisoners, drug users, and some people with mental health disorders, may need intensive support including DOTS.8 Locally appropriate measures should be undertaken to identify and address physical, financial, social and cultural barriers as well as health system barriers to accessing TB treatment services. Particular attention should be given to the poorest and most vulnerable population groups. Examples of actions that may be appropriate include expanding treatment outlets in the poorest rural and urban settings, involving providers who practice close to where patients live, ensuring that services are free or heavily subsidized, offering psychological and legal support, addressing gender issues, improving staff attitudes, and undertaking advocacy and communication activities. ln the case of confronting with a patient who is susceptible for non compliance

of medical treatment, the nurse could prepare the condition of compliance of treatment or involve him in DOTS program.10According to the importance of compliance of medical treatment in tuberculosis patients, the community health nurse in confronting with tuberculosis patients should focus to their self efficacy, sensitivity to the disease, attitudes toward the disease, beliefs, obstacles for the medical treatment and also their awareness of the advantages of the medical treatment.

London/Geneva (2005) stated that in most areas of the world, the battle against tuberculosis is being successfully fought, but in Africa the disease has reached alarming proportions with a growing number of TB cases and deaths linked to HIV, the World Health Organization said in a new report released today.The Global Tuberculosis Control report for 2005 finds that global TB prevalence has declined by more than 20% since 1990 and that incidence rates are now falling or stable in five of the six regions of the world. The glaring exception is Africa,where TB incidence rates have tripled since 1990 in countries with high HIV prevalence and are stillrising across the continent at a rate of 34% annually. Even Uganda, an African HIV reduction success story, is today curing fewer TB patients than itdid fouryears ago. More than half of all people with TB in Uganda remain without access to life-saving DOTS*services due to strained general health facilities. "Evidence in this report provides real optimism that TB is beatable, but it is also a clear warning," said WHO Director-General Dr LEE Jong-wook. "As Nelson Mandela has said, we can't fight AIDS unless we do much more to fight TB, and it is time to match his words with urgent action in Africa on the two

epidemics together."There has been major progress in China and India, which account for one third of the global TB burden. Both are leading the accelerated response to TB control by rapidly scaling up DOTS. As a result, the number of cases treated under DOTS worldwide rose 8% in 2003 compared to the previous year. Other countries such as Indonesia and the Philippines are showing similar progress. Assuming strong commitment and resources are sustained, four regions - the Americas, Eastern Mediterranean, South East Asia and Western Pacific - are on track to reach the United Nations Millennium Development Goal of reducing TB incidence by 2015. The two exceptions are Africa due to the TB/HIV coepidemic, and Europe where there are high levels of multidrug-resistant TB and slow advances in DOTS in countries of the former Soviet Union. "Dedicated frontline health workers are making a difference, reaching out to the most vulnerable," said Dr Mario Raviglione, Director of WHO's Stop TB Department. "But we need to push even further, to work with new partners in both public and private health sectors, and in all regions, to reach more than half of all patients that are still without access to DOTS treatments."Since 1995, over 17 million people with TB have benefited from effective treatment under DOTS. But more could be achieved within countries, and in research into new diagnostics, drugs and vaccines, if the annual US$ 1 billion funding gap for TB control was filled. The urgency of addressing TB has been highlighted in the UK-led Commission for Africa, which linked improved TB control to strengthened health systems, as well as calling for full funding of WHO's 'Two Diseases, One Patient' strategy for improved TB and HIV intervention. "It is a remarkable achievement that we are on target to reach the goal of halving TB cases by 2015 in most places," said the UK's International Development Secretary, Hilary Benn. "The Department for International Development is a strong supporter of TB programmes in some of

the countries which have been making the fastest progress. However, as both the Global TB Control report and the Commission for Africa report stress, the destructive link between TB and AIDS in Africa is causing an increase in cases. I call on the international community to step up efforts to tackle both of these diseases together.

Chaudhary (2002) stated that on analysis of the collected data reveals that 34.57% patients were from District TB Centre, Raipur, which is obvious because it is the district headquarters centre and more people attend with expectations of extra facilities in comparison to periphery, followed by BalodaBazar (15.13%), Dharsiwa (14.38%), Rajim(12.94%), Gariaband (12.23%) and Bhathapara (9.35%). Table 2 indicates that 463 (65.93%) in comparison to 232 (33.38%) patients complied as per DOTS, similar to the finding of Mehrotra et al (67.0%), Santha T et al (72%) and Bhat S et al (76.89%). A total of 232 patients, who did not consume the drugs for more than 2 consecutive weeks were considered as non compliant. The reasons for non comthree heads as suggested by Bansal AK et al. On further analysis, it was observed that out of the 232 non compliant patients, 140 (60.34%) patients failed to comply simply because of lack of information , whereas 7.75% and 31.89% were non-compliant because of lack of motivation and different obstacles, respectively. Various reasons observed in the present study for noncompliance are more or less similar to the findings of different studies conducted by different authors in different parts of the country. Main reason for noncompliance in the present study was having felt better (34.48%), similar to the findings of Juvekar SK et al at 27%. Non compliance due to fear of adversereactions was found in 20.26%, similar to the studies of

Bhat S et al (13.20%)(4) and Juvekar SK et al (10.0%). The 3rd most common cause of non compliance was found to be being moved away from the treatment centre (15.52%), similar to the findings of the study of Rani SM et al (22.0%). Other reasons for noncompliance were difficulty to find time from work to visit the centre (6.46%), difficulty to take so many pills and non availability of medicine (2.59%) etc., similar to the findings of other studies. It is therefore clear that to achieve the target of RNTCP, proper counseling of patients regarding various aspects of the disease is a must to ensure compliance.

Stigma-lurking on the edge of TB response, Stop-TB e-form (2004) Access and compliance to treatment for population groups with low access to health services, such as migrants or nomadic people, alternative models have been found including efforts to facilitate patients lives by reducing their need to come to a clinic, examples of home-based care in Cambodia and factory-based treatment in Thailand. To improve access to TB MSF for example increasingly has expanded TB treatment to conflict areas such as Afghanistan, South Sudan and Angola. To improve access to and responsiveness of health systems to the poor it is important to consider social factors such as stigma and responsiveness of health systems. The national TB program in Nicaragua is implementing a set of interventions to reduce the negative effects of TB-related stigma including: Review of care pathway of the patient in order to identify the many non-evidence base isolation precautions taken by health staff giving false ideas to the community about precautions to be taken with people

affected by TB .Develop TB clubs as a means to reinforce coping skills of TB patients. Develop psychosocial skills of health personnel. Organise case discussion amongst health staff centred on the psychosocial problems of patients. Stigma-lurking on the edge of TB response, Stop-TB e-form (2004) India, in order to attain community ownership, promoted its national TB programme as a peoples movement. Success of the Bangladeshi TB program partly resulted from the use of female community workers who earlier used to provide micro credits to poor women. This approach led to a doubling up of DOTS providers. Another important issue is the use of IEC activities to raise the level of awareness of the general public. If there is full coverage with DOTS, but low case detection rates, this can be addressed by aggressive marketing, as it is currently initiated with the socalled COMBI campaign in Kerala/India. In Peru an approach to improve drug adherence of the poor was to provide incentives to the patients such as food, subsidized transportation or loans for small businesses. These initiatives have helped to reach a cure rate of over 80 percent for MDR-TB patients. [1] Patient-Centered Outcomes Research (2010) stated that compliers believed that completing
treatment would cure them of TB. Economic prospects were crucial for compliance. Compliers felt that the support of the government disability grant helped with compliance. Non-compliers believed that stigmatization had the greatest impact on non-compliance, together with the burden of disease, the arrangements involved with receiving treatment, restrictions accompanying treatment, and the association of TB with HIV/AIDS infection.

[1]Patient-Centered Outcomes Research: 1 September 2010 - Volume 3 - Issue 3 - pp 159-172 doi: 10.2165/11531900-000000000-00000