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# Adherence To Anti-Tuberculosis Treatment and Soft Palate Tuberculosis:

Oscar Joshua Jataunamo

► To cite this version:

Oscar Joshua Jataunamo. Adherence To Anti-Tuberculosis Treatment and Soft Palate Tuberculosis: Cleft Palate Craniofacial Journal, 2025, Vol. 1. hal-05003348

HAL Id: hal-05003348

https://hal.science/hal-05003348v1

Submitted on 24 Mar 2025

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ADHERENCE TO ANTI-TUBERCULOSIS TREATMENT AND SOFT PALATE
TUBERCULOSIS: A STUDY IN PRIMARY HEALTH CARE, BABBAN DODO,
ZARIA, NIGERIA.

BY:

JOSHUA JATAUNAMO OSCAR FWAPCNM

(RN, RM, RNAS, RNE, BNSc, PDGE, MSc, FWACN PhD in View).

Email: joshuaoscar21@gmail.com

Department of Nurse Anaesthesia Programme, College of Nursing Sciences. Ahmadu
Bello University Teaching Hospital, Zaria Kaduna State, Nigeria.

**Abstract**

Tuberculosis (TB) remains a significant public health concern globally, with pulmonary TB being the most common form. However, extrapulmonary manifestations, such as soft palate TB, are rare and often misdiagnosed due to their similarity to other oral lesions. This study investigates adherence to anti-TB treatment and explores a case of soft palate TB in a primary healthcare setting in Babban Dodo, Zaria, Nigeria. A cross-sectional research design was employed, with data collected from 48 respondents using structured questionnaires. Findings revealed that socio-economic factors, health service inefficiencies, and patient-related barriers significantly impact treatment adherence. Poverty, ignorance, long distances to healthcare facilities, drug shortages, and delays in treatment were identified as major challenges. Additionally, stigma and socio-cultural beliefs influenced patient compliance. Despite widespread knowledge about TB treatment sources, adherence rates remain suboptimal, contributing to drug resistance and prolonged disease transmission. The study underscores the need for improved patient education, better healthcare worker training, and strengthened support systems such as Directly Observed Treatment (DOT) to enhance adherence. Addressing systemic barriers and promoting early diagnosis of rare TB manifestations like soft palate TB can improve treatment outcomes. Future research should focus on qualitative analyses to explore patient experiences and devise more effective adherence strategies.

**Introduction**

Tuberculosis (TB) remains a significant
public health issue globally, even in the 21st
century (WHO, 2020:3). While pulmonary
TB is the most common form,

extrapulmonary manifestations, including
soft palate tuberculosis, are rare and often
misdiagnosed. Adherence to anti-
tuberculosis treatment is critical for disease
control and prevention of drug resistance.
Tuberculosis (TB) infection is caused by the
Mycobacterium species, most commonly M.Tuberculosis. It commonly affects the lungs but could also present as extrapulmonary or secondary TB by residing in other organs such as skin, bone, gastrointestinal tract, genitourinary system and oral cavity. Extra-pulmonary TB accounts for approximately 10-15 % of TB cases while only 0.2 - 1.5 % of these cases occurs in the oral cavity as secondary to pulmonary TB (Amuha, Kutyami, Kutotu, Odoi- Adome, and Kalyango (2019).

Pulmonary TB is the common presentation of TB with the classical symptom of a productive cough. TB can spread to the oral cavity through either infected sputum or through a hematogenous route (Cambanis, 2017). Oral TB is uncommon and has various clinical pictures, which makes it easier to miss in diagnosis. It commonly presents as ulcers, granules or indurated soft tissue lesions. It can be commonly found on the tongue but can also be seen in other sites such as the lip, cheeks, soft palate, and uvula, gingival and alveolar mucosa (Cambanis, 2017).

In Nigeria, TB is among the leading causes of illness and death, posing a significant challenge to the National Department of Health (2019:9). Despite the availability of highly effective treatment regimens with over 95% success rates for drug-susceptible TB, non-compliance with treatment remains a pressing issue in many parts of Africa. For instance, non-adherence rates in Uganda (13.0%), Nigeria (10.0%), and other regions reflect this ongoing challenge (Vieira & Ribera, 2011:215-227). Consequently, thousands of TB-related deaths occur

annually (WHO, 2020:3). Drug-resistant TB exacerbates the situation, contributing to a mortality rate of 40 per 100,000 people (WHO, 2020:4).

## The Role of Compliance in TB Control

Treatment compliance is central to controlling TB, with evidence suggesting that poor adherence significantly impacts disease transmission and the emergence of multidrug-resistant TB (MDR-TB) (Setswe, 2009:3). In Nigeria, treatment adherence remains low, with defaulter rates as high as 12% (WHO, 2010:6). Non-compliance is influenced by multiple factors, including healthcare system inefficiencies, therapy-related challenges, socioeconomic barriers, and patient-related issues (National Department of Health, 2009:47).

Efforts to improve compliance, such as Nigeria's client-centered TB control program, aim to make TB services more accessible and increase the treatment cure rate to 85% (National Department of Health, 2009:11). However, adherence remains a complex issue with far-reaching consequences, including prolonged disease transmission, treatment failure, and increased mortality rates.

## Defining and Addressing Non-Compliance

Adherence to TB treatment is inconsistently defined, complicating comparisons across studies. Generally, it involves consistent medication intake and attendance at follow-up appointments (Medonca et al., 2016). Non-compliance, whether primary (not filling prescriptions) or secondary (not
taking medication as prescribed), undermines TB control efforts, leading to drug resistance and poor patient outcomes (Kulkarni et al., 2013; Tesfahuneygn et al., 2015).

Studies emphasize the need for strategies to address non-compliance determinants, including physical, financial, social, and cultural barriers (Raviglione, 2009; Tesfahuneygn et al., 2015). Programs like the WHO's Directly Observed Treatment Short Course (DOTS) and "Stop TB" strategy advocate for patient-centered care to improve adherence rates and reduce the TB burden (WHO, 2010:78).

## Challenges and Solutions in TB Management

The Nigeria National TB Control Programme (NTCP) adopted DOTS in 1996, encouraging the involvement of support persons to enhance treatment adherence (WHO, 2011b:27). The strategy emphasizes increased detection and successful treatment rates while addressing barriers to compliance. Key recommendations include using fixed-dose combination drugs to reduce pill burden, strengthening patient education, and making TB services accessible and culturally appropriate (WHO, 2011b:61; National Department of Health, 2009:37).

## Study Context and Objectives

This study focuses on understanding factors influencing adherence to TB treatment

among adult TB patients at the Primary Health Care (PHC) facility in B/Dodo, Zaria. Key objectives include:

1. Identifying factors affecting adherence to TB treatment.

2. Assessing patients' knowledge about TB treatment.

3. To document a rare case of soft palate tuberculosis and its clinical presentation.

4. Exploring socio-cultural factors related to non-compliance.

5. Examining treatment compliance patterns among patients.

The findings aim to inform strategies for increasing adherence, reducing defaulter rates, and improving overall patient outcomes.

## Significance of the Study

By exploring patient and health-service-related factors affecting TB treatment adherence, this study contributes to the broader understanding of compliance issues. It supports the development of targeted interventions to improve adherence, decrease defaulter rates, and enhance patient outcomes, ultimately strengthening TB control efforts.

## Definitions of Key Concepts

1. **Compliance:** Consistently taking prescribed TB medication as directed, including maintaining the correct dosage, timing, and dietary restrictions throughout the treatment duration.
2. **DOTS (Directly Observed Treatment Units):** A WHO-endorsed strategy for TB management, emphasizing patient observation, drug availability, and comprehensive case management.

3. **Non-Compliance:** Any interruption in TB treatment, such as missing doses or failing to complete the prescribed course.

4. **Pulmonary TB:** Tuberculosis affecting the lungs, diagnosed via laboratory or clinical methods.

5. **First-Line TB Drugs:** Primary drugs for TB treatment, including Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol.

6. **Second-Line TB Drugs:** Medications for treating drug-resistant TB, used when first-line treatments are ineffective.

## LITERATURE REVIEW

This chapter presents a literature review aimed at identifying factors contributing to non-compliance with TB treatment in primary healthcare (PHC) settings. It synthesizes evidence from various global sources, including textbooks, research, WHO reports, district reports, and Department of Health publications, focusing on TB treatment compliance.

### Soft Palate Tuberculosis

Soft palate tuberculosis is a rare form of extrapulmonary tuberculosis that affects the oral cavity. It is often misdiagnosed due to its similarity in presentation to malignancies,

fungal infections, and autoimmune diseases. The condition is caused by *Mycobacterium tuberculosis*, which typically affects the lungs but can spread to other parts of the body, including the oral mucosa, through hematogenous dissemination or direct inoculation (Hashimoto 2019).

### Epidemiology

Oral tuberculosis accounts for less than 1% of all TB cases. The soft palate is an uncommon site for TB infection, with most cases reported in individuals with a history of pulmonary tuberculosis or immunosuppression, such as HIV/AIDS, diabetes, or prolonged corticosteroid use (Verma S, Mohan RP, Singh U, Agarwal 2020.).

### Pathogenesis

The pathogenesis of soft palate tuberculosis involves:

* **Primary infection:** Occurs when *M. tuberculosis* directly invades the oral mucosa through a breach in the epithelium, such as ulcers, dental extractions, or trauma.

* **Secondary infection:** More common and results from hematogenous spread from an existing focus of TB infection, typically the lungs.

* **Lymphatic spread:** The infection can spread from nearby lymph nodes to the soft palate.

### Clinical Presentation

Patients with soft palate tuberculosis may present with:
* A non-healing ulcer on the soft palate

* Pain or burning sensation while eating or drinking

* Dysphagia (difficulty swallowing)

* Chronic irritation and discomfort

* Weight loss and systemic symptoms like fever and night sweats in advanced cases

* Enlarged cervical lymph nodes in some cases

## Diagnosis

Diagnosing soft palate tuberculosis requires a combination of clinical, histopathological, and microbiological investigations:

* **Histopathology:** Biopsy of the lesion typically reveals granulomatous inflammation with caseous necrosis.

* **Acid-Fast Bacilli (AFB) Staining:** Identification of *M. tuberculosis* under a microscope.

* **Polymerase Chain Reaction (PCR):** Detects *M. tuberculosis* DNA, confirming the diagnosis.

* **Chest X-ray and Sputum Examination:** To rule out or confirm pulmonary TB.

* **Tuberculin Skin Test (Mantoux Test):** Helps determine TB exposure.

## Differential Diagnosis

Soft palate tuberculosis can mimic several conditions, making differential diagnosis crucial. These include:

* Squamous cell carcinoma

* Fungal infections (e.g., candidiasis, histoplasmosis)

* Syphilitic ulcerations

* Traumatic ulcers

* Autoimmune conditions like pemphigus vulgaris

## Treatment and Management

The treatment of soft palate tuberculosis follows the standard anti-tubercular therapy (ATT) regimen, which includes:

* **Intensive Phase (2 months):** Combination of isoniazid, rifampicin, pyrazinamide, and ethambutol.

* **Continuation Phase (4–6 months):** Isoniazid and rifampicin.

* **Adjunctive Therapy:** Includes analgesics for pain management, nutritional support, and treatment of underlying immunosuppressive conditions if present.

* **Monitoring:** Regular follow-ups to assess lesion healing, adherence to treatment, and evaluation of drug side effects.

## Prognosis

With early diagnosis and proper treatment, the prognosis of soft palate tuberculosis is
generally favorable. Complete healing of the lesion is expected within a few months of initiating ATT. However, delayed treatment or misdiagnosis may lead to complications such as extensive tissue damage, secondary infections, or systemic spread of TB.

## Prevention

* Early diagnosis and treatment of pulmonary TB to prevent dissemination.

* Strengthening public health programs to improve awareness and adherence to TB treatment.

* Screening high-risk individuals, such as those with HIV/AIDS or immunosuppression, for TB.

* Improving healthcare accessibility in rural and underserved areas.

## Initiation into TB Therapy:

In line with WHO guidelines, patients showing symptoms of TB (persistent cough, sputum production, weight loss, fatigue, night sweats) undergo diagnostic testing. In Nigeria, TB treatment is initiated based on positive sputum results, with decentralization from hospitals to primary healthcare centers to improve access and timeliness. Treatment involves various regimens depending on the patient's case (new, retreatment, children, MDR TB).

## Compliance to TB Treatment:

Compliance refers to patients taking their prescribed TB medication correctly and consistently for the required six months. The WHO emphasizes addressing physical,

financial, social, and cultural barriers to compliance. The DOTS strategy, which includes Directly Observed Treatment (DOT), has been adopted to enhance adherence. South Africa's DOT implementation includes three types: clinic-based (observed in healthcare facilities), workplace-based (for employees), and community-based DOT (observed at home). Each has its advantages and challenges, especially in terms of accessibility and accountability.

## Non-Compliance Levels:

Non-compliance is measured by treatment success rates (above 85%) and should ideally be under 5%. In Nigeria, the TB cure rate is currently below target (69%), with 7% of patients non-compliant in 2010. Non-compliance leads to poor treatment outcomes, including drug resistance, and increases the risk of prolonged infection. Factors contributing to non-compliance include the lengthy treatment duration (6 months) and the toxicity of TB drugs. Compliance has significant benefits, including complete cure, prevention of new infections, reduced drug resistance, and lessened community transmission.

## Factors Affecting Compliance to TB Treatment: Summary

Compliance to tuberculosis (TB) treatment involves following medical advice and completing prescribed therapy. Several factors influence compliance, categorized into demographic, health-service, client-related, social, and economic aspects:

### 1. Demographic Factors
* **Age:** Patients over 25 are generally more compliant, though studies present mixed findings.

* **Educational Status:** Higher education correlates with better compliance due to improved understanding of TB and treatment protocols.

* **Family Support:** Evidence on family support's impact on compliance is inconclusive.

* **Gender and Marital Status:** Non-compliance is higher among males (63%) and married individuals (72%).

## 2. Health-Service Factors

* **Treatment Duration:** Lengthy therapies discourage compliance, leading to treatment interruptions and drug resistance.

* **Access to Treatment:** Distance from health facilities and poor infrastructure hinder access, affecting compliance negatively.

* **Staff Attitudes:** Negative behaviors from healthcare workers discourage patients from adhering to treatment.

* **Patient-Provider Relationships:** Effective communication and support enhance compliance.

## 3. Client-Related Factors

* **Cultural Beliefs:** Traditional views can conflict with medical advice, leading to non-compliance.

Collaboration with traditional healers is recommended.

* **Poverty and Socio-Economic Status:** Poor patients face barriers such as costs and access, increasing the likelihood of non-compliance.

* **Knowledge of TB:** Patients with greater knowledge about TB are more likely to adhere to treatment.

## 4. Social Factors

* **Stigma and Discrimination:** Fear of social judgment can deter patients from seeking or continuing treatment.

* **Co-Morbidities:** Conditions like HIV increase treatment complexity and pill burden, reducing compliance.

## 5. Perceived Severity of Ill-Health

* Patients often discontinue treatment when symptoms subside, mistaking temporary relief for a cure.

## 6. Measuring Compliance

* **Direct Methods:** Include observing medication intake and measuring drug levels in the body.

* **Indirect Methods:** Involve self-reports, pill counts, and clinic attendance monitoring.

* **The Directly Observed Treatment Strategy (DOTS) ensures patients take medication properly, improving cure rates and reducing drug resistance.**
Non-compliance is a major challenge, leading to treatment failure and drug resistance. Strategies such as DOTS have significantly improved treatment outcomes globally, emphasizing the need for integrated support systems to address the various barriers.

# Theoretical and Conceptual Framework: Summary

## Health Belief Model (HBM)

The Health Belief Model (HBM) is the conceptual framework for this study, developed in the 1950s to understand health-related behaviors, such as compliance with TB treatment. It emphasizes that personal beliefs significantly influence health behaviors. The key constructs explored include:

### 1. Perceived Seriousness/Severity

* Refers to an individual's belief about the severity of a disease, influenced by medical knowledge and perceived life impact. This study evaluates participants' knowledge about the consequences of non-compliance with TB treatment.

### 2. Perceived Susceptibility

* Describes an individual's perception of their vulnerability to a health problem or belief in the

accuracy of a diagnosis. The study assesses whether participants perceive TB as a personal health concern.

### 3. Perceived Benefits

* Represents the belief in the effectiveness of adopting a health behavior, such as completing TB treatment, to improve health outcomes. Compliance is linked to patients' belief in the treatment's benefits.

### 4. Perceived Barriers

* Relates to obstacles preventing behavior change. These barriers are influenced by factors like culture, education, motivation, and personal experiences. Identifying these barriers helps address non-compliance.

The HBM is relevant as it connects health behavior (TB treatment compliance) to personal beliefs and strategies for reducing disease occurrence.

## Summary of Literature Review

The chapter covered:

* **Tuberculosis (TB):** Its nature, treatment initiation, and compliance, focusing on Directly Observed Therapy (DOT) in clinical, workplace, and community settings.

* **Factors Influencing Compliance:**
* **Demographic Factors:** Age, education, family support, gender, and marital status.

* **Health Service Factors:** Treatment duration, access to care, staff attitudes, and patient-provider relationships.

* **Client-Related Factors:** Cultural beliefs, poverty, socioeconomic status, and TB knowledge.

* **Social Factors:** Stigma, discrimination, and co-morbidities.

* **Measuring Compliance:** Highlighted its role in evaluating treatment success, using tools like observation, self-reporting, and attendance tracking.

* **Theoretical Framework:** The HBM emphasizes the role of personal beliefs in health behavior and strategies to enhance compliance.

This comprehensive review integrates TB treatment challenges, compliance factors, and theoretical insights to provide a structured understanding of patient behaviors.

## Methodology

The methodology, covered the research design, study area, population, sampling techniques, data collection instruments, validity and reliability, methods of data collection, and data analysis.

## Research Design

The study utilized a cross-sectional design, selected for its efficiency, cost-effectiveness, and suitability for identifying factors influencing adherence to anti-TB treatment within a limited timeframe.

## Study Area

The research was conducted in B/Dodo Primary Health Care, Zaria City, Kaduna State, Nigeria. Zaria, historically known as Zazzau, is a culturally and historically significant city with a population of approximately 408,198 (2006 census). The area is known for its educational and historical landmarks, including Ahmadu Bello University and the Zazzau Emirate.

## Study Population

The target population consisted of 200 individuals, including health workers and TB patients (active, defaulters, or those who completed treatment) attending the DOT clinic.

## Sampling and Sampling Method

The study required a minimum sample size of 50 patients, selected using a convenience sampling technique, which was deemed appropriate for a social science study of this nature.

## Data Collection Instrument
A structured questionnaire was used, divided into sections covering demographic data and specific research questions. This instrument ensured efficient data collection, confidentiality, and objective responses.

## Validity and Reliability

The questionnaire's design facilitated data collection from a large sample in a short timeframe while maintaining participant confidentiality, ensuring candid and reliable responses.

## Data Collection Method

An interviewer-administered questionnaire was used during patient queues for TB
**Results**

This section presents the analysis of data collected from 48 out of 50 administered questionnaires, using the mean statistical method to address the research questions.

## Section A: Respondent Demographics

<table><thead><tr><td>Age</td><td>Frequency</td><td>Percentage %</td></tr></thead><tbody><tr><td>18-25</td><td>2</td><td>4.2</td></tr><tr><td>26-33</td><td>14</td><td>29.2</td></tr><tr><td>34-41</td><td>16</td><td>33.3</td></tr><tr><td>42-49</td><td>12</td><td>25</td></tr><tr><td>50-Above</td><td>4</td><td>8.3</td></tr><tr><td>Total</td><td>48</td><td>100</td></tr></tbody></table>

* Age: Most respondents (33.3%) were aged 34–41 years.

* Gender: Males constituted the majority at 52.1%.

* Marital Status: A significant majority (83.3%) of respondents were married.

## Section B: Factors Influencing Adherence to Anti-TB Drugs

<table><thead><tr><td>S/N</td><td>Items</td><td>SA</td><td>A</td><td>SD</td><td>D</td><td>Mean</td><td>Remarks</td></tr></thead><tbody><tr><td>1</td><td>Poverty</td><td>80</td><td>30</td><td>22</td><td>7</td><td>2.9</td><td>Agreed</td></tr><tr><td>2</td><td>Ignorance on health matters</td><td>48</td><td>102</td><td>2</td><td>1</td><td>3.2</td><td>Agreed</td></tr><tr><td>3</td><td>Negative attitude of health Worker</td><td>24</td><td>90</td><td>4</td><td>10</td><td>2.7</td><td>Agreed</td></tr></tbody></table>

services. Questions were translated into the local language to enhance understanding.

## Data Analysis

Data were analyzed with descriptive statistics using MS Excel 2008, with a focus on summarizing and interpreting findings effectively.

This methodology provides a robust framework for assessing factors influencing adherence to anti-TB treatment.

Results:
<table><tr><td>4</td><td>Distance between health clinic</td><td>24</td><td>102</td><td>8</td><td>4</td><td>2.9</td><td>Agreed</td></tr><tr><td>5</td><td>Shortage of drugs</td><td>24</td><td>78</td><td>16</td><td>8</td><td>2.6</td><td>Agreed</td></tr><tr><td>6</td><td>Delay in health facility</td><td>8</td><td>90</td><td>16</td><td>8</td><td>2.5</td><td>Agreed</td></tr><tr><td>7</td><td>Insecurity</td><td>32</td><td>60</td><td>28</td><td>6</td><td>2.6</td><td>Agreed</td></tr><tr><td>8</td><td>Poor mobilization</td><td>64</td><td>72</td><td>6</td><td>5</td><td>3.1</td><td>Agreed</td></tr><tr><td>9</td><td>Lack of government commitment</td><td>40</td><td>96</td><td>4</td><td>4</td><td>3.0</td><td>Agreed</td></tr><tr><td>10</td><td>Workers strike</td><td>24</td><td>69</td><td>24</td><td>8</td><td>2.6</td><td>Agreed</td></tr><tr><td>11</td><td>Political Influences</td><td>16</td><td>60</td><td>16</td><td>16</td><td>2.3</td><td>Disagreed</td></tr><tr><td>12</td><td>Cultural factors</td><td>12</td><td>48</td><td>16</td><td>13</td><td>1.9</td><td>Disagreed</td></tr><tr><td>13</td><td>Lack of relative and family commitment</td><td>16</td><td>60</td><td>16</td><td>6</td><td>2.0</td><td>Disagreed</td></tr><tr><td>14</td><td>Stigma</td><td>40</td><td>78</td><td>8</td><td>8</td><td>2.8</td><td>Disagreed</td></tr></table>

Respondents identified the following as key factors influencing adherence:

* Agreed factors: poverty, ignorance, negative attitudes of health workers, distance to clinics, drug shortages, delays in facilities, insecurity, poor mobilization, lack of government commitment, and workers' strikes (mean: 2.9).

* Disagreed factors: political influences, cultural factors, lack of family support, and stigma.

## Section C: Patient Knowledge About TB Treatment

<table><thead><tr><th>S/N</th><th>Items</th><th>SA</th><th>A</th><th>SD</th><th>D</th><th>Mean</th><th>Remark</th></tr></thead><tbody><tr><td>1</td><td>I heard through health personnel at health clinic</td><td>80</td><td>60</td><td>4</td><td>6</td><td>2.3</td><td>Disagreed</td></tr><tr><td>2</td><td>I heard from public enlighten</td><td>24</td><td>96</td><td>12</td><td>4</td><td>2.8</td><td>Agreed</td></tr><tr><td>3</td><td>I heard from my neighbors</td><td>24</td><td>90</td><td>8</td><td>8</td><td>2.7</td><td>Agreed</td></tr><tr><td>4</td><td>I heard from relatives</td><td>16</td><td>87</td><td>12</td><td>9</td><td>2.6</td><td>Agreed</td></tr><tr><td>5</td><td>I heard from social flat form</td><td>24</td><td>90</td><td>12</td><td>6</td><td>2.8</td><td>Agreed</td></tr><tr><td>6</td><td>I heard through outreach</td><td>12</td><td>84</td><td>24</td><td>5</td><td>2.6</td><td>Agreed</td></tr><tr><td>7</td><td>I heard through community town meeting</td><td>32</td><td>90</td><td>4</td><td>8</td><td>2.8</td><td>Agreed</td></tr><tr><td>8</td><td>I heard from school</td><td>40</td><td>87</td><td>6</td><td>6</td><td>2.8</td><td>Agreed</td></tr></tbody></table>

The respondents demonstrated sound knowledge of TB treatment sources, agreeing that they received information from public enlightenment, neighbors, relatives, social platforms, outreach programs, community meetings, and schools (mean: 2.7). Only one item, "hearing through health personnel," was disagreed upon.
## Section D: Factors Responsible for Non-Compliance

<table><thead><tr><th>S/N</th><th>Items</th><th>SA</th><th>A</th><th>SD</th><th>D</th><th>Mean</th><th>Remark</th></tr></thead><tbody><tr><td>1</td><td>Demographic factors</td><td>36</td><td>42</td><td>18</td><td>18</td><td>2.1</td><td>Disagreed</td></tr><tr><td>2</td><td>Health service factors</td><td>40</td><td>84</td><td>4</td><td>8</td><td>2.2</td><td>Disagreed</td></tr><tr><td>3</td><td>Client-Related factors</td><td>36</td><td>90</td><td>1</td><td>8</td><td>2.8</td><td>Agreed</td></tr><tr><td>4</td><td>Social factors</td><td>12</td><td>60</td><td>16</td><td>17</td><td>2.2</td><td>Disagreed</td></tr><tr><td>5</td><td>Economic factors</td><td>40</td><td>84</td><td>10</td><td>5</td><td>2.9</td><td>Agreed</td></tr></tbody></table>

* **Agreed Factors:** Client-related factors and economic challenges (mean: 2.4).

* **Disagreed Factors:** Demographic, health service, and social factors.

## Section E: Relationship Between Compliance and Socio-Cultural Behavior

<table><thead><tr><th>S/N</th><th>Items</th><th>SA</th><th>A</th><th>SD</th><th>D</th><th>Mean</th><th>Remark</th></tr></thead><tbody><tr><td>1</td><td>Culture</td><td>44</td><td>60</td><td>10</td><td>12</td><td>2.6</td><td>Agreed</td></tr><tr><td>2</td><td>Believe</td><td>24</td><td>108</td><td>8</td><td>2</td><td>3.0</td><td>Agreed</td></tr><tr><td>3</td><td>Taboos</td><td>40</td><td>90</td><td>6</td><td>5</td><td>2.9</td><td>Agreed</td></tr><tr><td>4</td><td>Discrimination</td><td>64</td><td>84</td><td>4</td><td>2</td><td>3.2</td><td>Agreed</td></tr><tr><td>5</td><td>Respect</td><td>32</td><td>57</td><td>20</td><td>11</td><td>2.5</td><td>Agreed</td></tr><tr><td>6</td><td>Perceptions</td><td>8</td><td>64</td><td>8</td><td>10</td><td>1.9</td><td>Disagreed</td></tr><tr><td>7</td><td>Communication</td><td>16</td><td>72</td><td>20</td><td>10</td><td>2.5</td><td>Agreed</td></tr></tbody></table>

Respondents agreed on the following socio-cultural influences on compliance:

* Culture, beliefs, taboos, discrimination, respect, and communication (mean: 2.7).

* Perceptions were not seen as significantly affecting compliance.

## Discussion of Findings

The findings of this study were discussed in relation to the respondents' demographics and research questions.

## Bio-Data of Respondents

Table 4.1.1 highlights that the majority of respondents were aged 34–41 years (33.3%), followed by 26–33 years (29.2%). Most respondents were male (52.1%), and a significant proportion (83.3%) were married. This demographic distribution indicates a diverse but predominantly middle-aged and married population.

## Research Question 1: Factors Influencing Adherence to Anti-Tuberculosis Drugs
The study revealed several factors influencing adherence to TB medication, with respondents agreeing on the following key factors:

* Poverty, ignorance, negative attitudes of healthcare workers, distance to clinics, drug shortages, and delays in health facilities.

* Other agreed factors include insecurity, poor mobilization, lack of government commitment, and workers' strikes.

Factors like political influences, cultural barriers, family support, and stigma were disagreed upon as significant. These findings align with the National Department of Health and WHO, which emphasize that non-adherence significantly impacts treatment outcomes, leading to drug resistance and prolonged treatment challenges.

**Research Question 2: Patients' Knowledge About TB Treatment**

Respondents demonstrated sound knowledge of TB treatment, agreeing on receiving information from public enlightenment, neighbors, relatives, community meetings, and schools. Only one item, "hearing from health personnel," was disagreed upon. The findings corroborate previous studies, such as Ghani (2010), which highlight that higher education and awareness levels among patients correlate with better treatment compliance and outcomes.

**Research Question 3: Factors Responsible for Non-Compliance**

Respondents disagreed with demographic, health service, and social factors as reasons for non-compliance but agreed on client-related and economic challenges. Non-compliance in Nigeria is a significant issue, with only a 69% cure rate (WHO, 2011), far below the 85% target. Poor compliance leads to drug resistance and inadequate treatment, as emphasized by Harrison (2001).

**Research Question 4: Relationship Between Compliance and Socio-Cultural Behavior**

Socio-cultural factors like culture, beliefs, taboos, discrimination, and communication were identified as influential. However, perceptions were not considered significant. Studies by Hodgson et al. (2004) and Ghani (2010) highlight the negative impact of stigma and discrimination, which deter patients from seeking timely treatment and support.

**Limitations of the Study**

* Not all respondents participated, potentially limiting data reliability.

* Self-reported data on adherence could not be independently verified.

* Absence of pharmacists in TB management limited comprehensive medication education and adherence counseling.

**Conclusions**
Adherence to TB treatment at the Babban Dodo Primary Health Center is influenced by factors such as patient knowledge, clinic accessibility, counseling quality, and socio-economic challenges. Strengthening health worker-patient relationships and addressing economic and logistical barriers are critical to improving adherence rates.
## Recommendations

1. Intensify Health Education: Educate TB patients on treatment duration, side effects, and risks of incomplete therapy, using local languages.

2. Involve Traditional Healers: Partner with traditional practitioners to discourage misleading claims and support TB control efforts.

3. Strengthen DOT: Ensure all patients receive direct observation throughout their treatment to improve adherence.

4. Supportive Services: Link patients to programs providing food and social support to address economic challenges.

5. Improve Healthcare Worker Training: Train healthcare providers on customer care and stress management to enhance service quality.

6. Expand Mobile Outreach Services: Equip mobile healthcare teams with TB management skills to improve medication access in remote areas.

## Suggestions for Future Research

1. Conduct similar studies with a larger sample size across multiple districts for comparative analysis.

2. Undertake qualitative research exploring the lived experiences of TB patients to gain deeper insights into adherence challenges.
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