Case Study - 1

Effective Counseling in Health Facilities helps increasing Case Findings and retaining Clients in Treatment

Mr. Basanta Kumar Bhattarai, an employee of District Health Office in Pokhara has been serving as a District TB/Leprosy Officer (DTLO) since long. He has lots of experience in motivating and caring people for tuberculosis and leprosy. During the orientation session, Mr. Bhattarai shared the situation of tuberculosis in Kaski district and informed the participants that the cure rate of TB in the district is 93% whereas the remaining 7% were dropped out due to family and social stigma, economic condition and migration. But, he believes if emphasize could be given in counseling services in health facility, case finding as well as client retention improves resulting low incidence of drug resistance tuberculosis (DR-TB). He shared an incidence to support his statement.

A client of a Brahmin (high class) community diagnosed as CAT I TB and started treatment under DOTS in his nearby treatment centre. After 90 days of treatment, his neighbors and relatives knew about the infection and started discrimination to him and his family. Due to the social stigma and discrimination, he dropped out from the treatment and migrated to another place to avoid stigma and discrimination.

Mr. Bhattarai was informed about the client by his subordinate and he himself involved in track the client. Finally, he got detailed information related to the whereabouts of the client and he went to meet him disguising him as a cattle trader. He found the person living with his wife but in a poor health with coughing and chest pain. Mr. Bhattarai started conversation with the person about cattle and his daily livelihood. After building a rapport with the person and his family, Mr. Bhattarai asked about his health condition and put a query on his coughing. At first the person did not intend to speak about his illness. When Mr.. Bhattarai shared the signs and symptoms as well as the easy way of treatment of tuberculosis, the person's wife told about the chronic coughing and chest problem of her husband. Mr. Bhattarai noticed blood in the sputum while the person was coughing during the conversation with him. The man was convinced with the talking of Mr. Bhattarai and shared his past history of TB treatment, the social and family stigma and discrimination he faced during the treatment in his previous place of living. Mr. Bhattarai realized the lacking of proper counseling from health workers and service providers while treating the client in the DOTS. Mr. Bhattrai assured the person and his wife about the confidentiality of the treatment at health facility. He also convinced the person that regular treatment of eight months recovers him fully from tuberculosis and there will be no anymore discrimination and stigma within the family and the community. With the in-depth counseling from Mr. Bhattrai, the client re-registered in the nearby DOTS centre and completed eight months treatment course. Now, he is fully cured of TB and living a happy life with his wife and family members. The person is still alive and feels thankful to Mr. Bhattrai for saving his life.

This is a good example to share that good counseling during medication increases case findings and decreases dropout rates. It also decreases the incidence of DR-TB. So, counseling during first visit of a client for seeking health services in health facilities is essential to have long-run impact of health services at the community level.

Mr. Bhattrai further emphasizes the importance of counseling, distribution of IEC materials like posters and pamphlets, door-to-door visits by health workers and volunteers by organizing household activities, street drama based on local language, culture and tradition. Besides that, he also suggested to launch Family and Community DOTS to make easy access in services for those who are living in poverty in remote and hard-to-reach communities.