Loss of employment and social stigma emerge proxy determinants of patient satisfaction in tuberculosis management under the National Tuberculosis Elimination Program: Reports from a single-center direct observation therapy strategy center in Bhubaneswar, Odisha.

Dear Editor, India has the world’s highest rate of tuberculosis (TB) infection. To mitigate this burden, the Indian government has been providing free treatment for TB under the direct observation therapy strategy (DOTS) since 1992 under a completely centrally owned program called the Revised National TB Program.[1] Bracing to face the challenge of TB elimination by 2025, the program is rechristened as the National TB Elimination Program (NTEP). The success of the program critically depends on the quality of care in the health-care setting and to suit the patient’s perspective and needs. TB default loss-to-follow-up rate in India ranges from 3% to 17%, which should be < 10%.[2,3] Patients who are satisfied with their clinical consultations or continuum of services are more likely to return to clinics for follow-up therapy and to adhere to treatment requirements. Thus, a measure of patient satisfaction provides input on programmatic performance.[4] The cross-sectional study was conducted at one DOTs center of a tertiary care hospital in Bhubaneswar with the primary objective to measure patient satisfaction with the services rendered under NTEP. This was assessed using a composite score build on 24 questions grading the current NTEP infrastructure, process, and outcome factors using a 5-point Likert scale (very satisfied to very dissatisfied), which was seen to have a cumulative Cronbach’s coefficient of 0.928. A preliminary analysis of the study indicates that employment is significantly associated with satisfaction. Out of 150 respondents, 125 (83%) reported the effect of DOTS service on employment/routine work/studies. A high satisfaction level was obtained on most factors with a weighted mean above 3.4 and dissatisfaction among 21 (14%) of the patients was reported with the transportation cost they paid, while 8 (5%) were not satisfied with a waiting time for treatment score being <3.4. Adherence to daily treatment was compromised among 25 (16%) participants, with diabetes comorbidity being significantly associated with treatment nonadherence (χ2 = 6.541, df = 1, P = 0.01). Patients who faced stigma from friends are 10.58 times less satisfied with DOTS service. TB program in India offers a megamix of diagnostics to drugs to financial compensation for nutrition and incentives for adherence to treatment. However, the disease burden often outnumbers and comprises the outcomes. Robust program delivery is undone by the continued social stigma and perhaps loss of wages incurred to adhere to the daily regime. Often, when the community knows that a person has TB, they debar them from work, which continues in areas of high incidence like Odisha, not understanding that an active case can be a threat to society and spread the infection further.[5] The study strongly hints that patient satisfaction scoring can help identify the weak links in the program and customize it as per local needs. Some social awareness campaigns may be designed, and means of rehabilitation or socioeconomic support should be devised under Rogi Kalyan Samitis or Community Health Associations to support estranged TB patients, especially in rural areas or small cities. TB does not have a social pathology alone but also clearly has social determinants of stigma and economic losses and hence the policymakers need to incorporate these concerns into the programmatic handholding. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.