10.2 Factors that influence adherence

• Socioeconomic factors such as having a job, a home, education, family or other support, being stigmatized or marginalized;
• Psychological factors such as depression and feelings of discouragement.
• Understanding and perception of the disease and treatment: a patient might continue or abandon treatment because s/he sees, or does not see, improvement. S/he might also have trouble taking an active part in treatment if s/he attributes the illness to supernatural causes, etc.

Personal difficulties should be discussed at patient visits. Solutions will depend on the context and the patient’s problem, and need to be found on a case-by-case basis

• Simplicity of treatment improves adherence. The use of fixed-dose combinations (FDCs) and introduction of shorter treatment courses simplifies the treatment by reducing the pill burden (number of tablets) as well as duration of treatment. In addition, FDCs also prevents the patient from selectively taking TB medication (by removing one or more medications from the blister packs).
• Adverse effects are often the reason why patients interrupt their treatment and hence, they must be quickly detected and adequately managed.

• Patient’s comfort and welfare is essential. Waiting times at clinics should be reasonable. For hospitalized patients, accommodations (comfort, food etc.) should be adequate.
• The relationship between the health care worker and the patient influences the adherence. If a patient trusts or has confidence in his/her health care worker, s/he is more likely to follow instructions and advice and to collaborate with the health care worker. Patients may also be more likely to bring questions and concerns to the health care worker's attention.
• Free care (visits, laboratory tests and treatment, including those related to management of adverse effects) limits the number of patients who abandon treatment for financial reasons.
• The co-management of HIV infection and TB requires coordination between the TB and HIV/AIDS programmes at all levels. Systems that set up a “one-stop service”, where patients receive both TB and HIV care, reduce the number of visits and decrease waiting times resulting in higher patient satisfaction and better results.
• Linkages for diagnosis and management of other comorbidities, like diabetes and hypertension, too can take place in the same clinic to decrease the burden on the patient and improve treatment outcomes.
• Drug supply management must be meticulous. It is essential to avoid shortages, which can lead to treatment interruption and negative impact adherence (patients waste time in pointless travel, loss of confidence in the clinic, etc.).