"DETERMINANTS OF TREATMENT SATISFACTION, ADHERENCE, AND COMPLIANCE AMONG PULMONARY TUBERCULOSIS PATIENTS IN THE KASHMIR VALLEY-NORTH INDIA: A CROSS-SECTIONAL STUDY"

Abstract

Background: India accounts for nearly 26% of the global tuberculosis (TB) burden, and the National TB Elimination Programme (NTEP) aims for elimination by 2025. The Kashmir valley presents unique geographical (mountainous terrain, harsh winters), socio-political , and cultural (stigma, traditional medicine) challenges that may influence TB treatment outcomes. However, limited empirical data exist on how treatment satisfaction and adherence interact in this setting.

Objective: To assess the level of treatment satisfaction, adherence, and compliance among pulmonary TB patients in the Kashmir valley, identify predictors of poor adherence, and explore patient-reported barriers.

Methods: A mixed-methods study was conducted from November 2021 to November 2022 across three districts of Kashmir Division (Srinagar – urban, Baramulla-Peri urban, and Kulgam Rural ). A total of 372 adult patients (≥18 years) with drugsensitive pulmonary TB on Category I or II DOTS regimen for at least 2 months were enrolled using stratified random sampling. Quantitative data were collected using: (i) Morisky Medication Adherence Scale (MMAS-8) – scores <6 defined as low adherence; (ii) TB Treatment Satisfaction Questionnaire (SAT-Q-TB); (iii) Patient Health Questionnaire (PHQ-9) for depression. Compliance (supervised drug intake) was verified from DOT centre records. Qualitative indepth interviews (n=30) were conducted with nonadherent patients. Multivariate logistic regression identified predictors of poor adherence.

Results: Of 372 participants (mean age 41.3±14.7 years; 54.8% male), the overall adherence rate (MMAS-8 ≥6) was 71.2% (265/372). Compliance (DOT recordverified supervised intake ≥80% of doses) was lower at 64.5% (240/372). Treatment satisfaction (mean SAT-Q-TB score 68.4±12.1 out of 100) was moderate, with lowest scores for “waiting time at DOT centre” (mean 5.2/10) and “information on side effects” (mean 5.8/10).

Key predictors of poor adherence (adjusted odds ratio, 95% CI):Distance to DOT centre >5 km – aOR 3.4 (1.9–6.1)Moderate/severe depression (PHQ-9 ≥10) – aOR 2.9 (1.6–5.2)Experiencing any drug side effect (e.g., nausea, rash, arthralgia) – aOR 2.5 (1.4–4.5)Monthly household income <₹10,000 – aOR 2.1 (1.2–3.7)District-wise adherence: Srinagar (urban) 78.4%, Baramulla(semi-urban) 69.1%, Kulgam (rural) 63.8% (p=0.008).Qualitative findings revealed five major barriers:Winter inaccessibility (roads closed for 2–4 months, especially in high-altitude areas).Fear of stigma (“people avoid sharing utensils”).Financial cost of travel to DOT centre (even when medicine is free).Perceived recovery before completion (“I felt better after 2 months, so I stopped”).

Conclusions: Adherence and compliance to TB treatment in the Kashmir valley are suboptimal (≈71% and 64% respectively), significantly lower than the NTEP target of ≥90%. Geographic isolation, mental health distress, side effects, and conflict-related disruptions are major independent barriers. Treatment satisfaction is only moderate, with weak patient education and long waiting times as key drivers.