The Patient: Patient-Centered Outcomes Research

, Volume 3, Issue 3, pp 159–172 | Cite as

Patient Views on Determinants of Compliance with Tuberculosis Treatment in the Eastern Cape, South Africa

An Application of Q-Methodology
  • Jane Murray Cramm
  • Job van Exel
  • Valerie Møller
  • Harry Finkenflügel
Original Research Article


Background: Tuberculosis (TB) constitutes one-quarter of all avoidable deaths in developing countries. In the Eastern Cape, South Africa, TB is a public health problem of epidemic proportion. Poor compliance and frequent interruption to treatment are associated with increased transmission rates, morbidity, and costs to TB control programs. This study explored determinants of (non-)compliance from the patients’ perspective.

Methods: Semi-structured interviews were conducted with patients (33 treatment compliers and 34 treatment non-compliers) and 14 community health workers from local community clinics and the hospital in the township of Grahamstown, Eastern Cape, South Africa. Q-methodology was used. Patients rank ordered 32 opinion statements describing determinants of treatment compliance from the TB adherence model. By-person factor analysis was used to explore patterns in the rankings of statements by compliers and non-compliers. These patterns were interpreted and described as patient views on determinants of compliance with treatment. Patients and community health workers selected the top five determinants of compliance and non-compliance.

Results: 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.

Conclusions: Stigmatization makes TB a ‘social disease’. Individual motivation and self-efficacy appear to have a considerable effect on compliance, but, for non-compliers, the general lack of job prospects and being able to provide for themselves or their family also makes TB very much an ‘economic disease’.


Community Health Worker Health Belief Social Stigma Score Sheet Avoidable Death 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this study. The authors have no conflicts of interest that are directly relevant to the content of this study.

The authors are grateful to the participating TB patients for taking the time to sit down with us and do the Q-sort interview, and to South Africa Netherlands research Programme on Alternatives in Development (SANPAD), Rhodes University and the hospital and clinics in Grahamstown East for their willingness and cooperation in conducting this study.


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Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  • Jane Murray Cramm
    • 1
  • Job van Exel
    • 1
    • 2
  • Valerie Møller
    • 3
  • Harry Finkenflügel
    • 1
  1. 1.Department of Health Policy and ManagementErasmus UniversityDR Rotterdamthe Netherlands
  2. 2.Institute for Medical Technology Assessment (iMTA)Erasmus UniversityRotterdamthe Netherlands
  3. 3.Institute of Social and Economic Research (ISER)Rhodes UniversityGrahamstownSouth Africa

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