TB control, poverty, and vulnerability in Delhi, India

Improving measurement of tuberculosis care cascades to enhance people-centred care

Care cascades represent the proportion of people reaching milestones in care for a disease and are widely used to track progress towards global targets for HIV and other diseases. Despite recent progress in estimating care cascades for tuberculosis (TB) disease, they have not been routinely applied at national and subnational levels, representing a lost opportunity for public health impact. As researchers who have estimated TB care cascades in high-incidence countries (India, Madagascar, Nigeria, Peru, South Africa, and Zambia), we describe the utility of care cascades and identify measurement challenges, including the lack of population-based disease burden data and electronic data capture, the under-reporting of people with TB navigating fragmented and privatised health systems, the heterogeneity of TB tests, and the lack of post-treatment follow-up. We outline an agenda for rectifying these gaps and argue that improving care cascade measurement is crucial to enhancing people-centred care and achieving the End TB goals.

Patient adherence to tuberculosis treatment in the Indian subcontinent: systematic review and meta-synthesis of qualitative research

OBJECTIVES

How well patients adhere to their tuberculosis (TB) treatment influences their recovery and development of drug resistance, but influences on adherence are multiple and often competing. We synthesised qualitative studies from our setting in the Indian subcontinent to understand the dimensions and dynamics involved to help inform service provision.

DESIGN

Qualitative synthesis comprising inductive coding, thematic analysis and forming a conceptual framework.

DATA SOURCES

Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), PsycINFO (EBSCOHost), Web of Science Core Collection, Cochrane Library and Epistemonikos were databases searched on 26 March 2020 for studies published since 1 January 2000.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included reports in English from the Indian subcontinent that used qualitative or mixed-methodology designs and reported findings around adherence to TB treatment. Full texts meeting eligibility were sampled based on 'thickness' (the richness of the qualitative data reported).

DATA EXTRACTION AND SYNTHESIS

Two reviewers used standardised methods to screen abstracts and code. Included studies were assessed for reliability and quality using a standard tool. Qualitative synthesis was performed by inductive coding, thematic analysis and developing conceptual framework.

RESULTS

Of 1729 abstracts screened from initial search, 59 were shortlisted for full-text review. Twenty-four studies that qualified as 'thick' were included in the synthesis. Studies were set in India (12), Pakistan (6), Nepal (3), Bangladesh (1) or in two or more of these countries (2). Of the 24 studies, all but one included people who were taking TB treatment (1 study included only healthcare providers), and 17 included healthcare workers, community members or both.We identified three themes: (1) personal influences on the people with TB include interconnections between their social role in the family unit, their own priorities in day-to-day living and their experience to date with the disease; (2) adherence is profoundly influenced by how individual healthcare providers interact with patients on treatment and address their needs; (3) adherence is influenced across communities by structural, social, economic and cultural factors related to treatment.

CONCLUSION

Staff in TB programmes require an understanding of the various competing influences on individuals undergoing treatment. Programmes need to have more flexible and people-centred approaches to service provision in order to achieve adherence, and thus improve treatment outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020171409.

Factors predicting self-report adherence (SRA) behaviours among DS-TB patients under the "Integrated model": a survey in Southwest China

BACKGROUND

China is one of 30 countries with a high tuberculosis (TB) burden, and poor adherence to TB treatment is one of the biggest challenges for TB control. We aimed to explore the barriers and facilitators of treatment adherence among drug-sensitive tuberculosis (DS-TB) patients under the "Integrated model" in Western China, to provide evidence-based treatment and control regimens for DS-TB patients to improve adherence behaviours.

METHODS

Both qualitative and quantitative research methods were used to explore the factors associated with self-reported adherence (SRA) behaviours. Questionnaire surveys with DS-TB patients and in-depth interviews with leaders from the Centers for Disease Control and Prevention (CDC) and community health sectors (CHCs), healthcare workers (HCWs) from CHCs, and DS-TB patients were conducted.

RESULTS

A total of 459 eligible patients were included in the quantitative survey, and two patients and 13 healthcare providers were included in the in-depth interviews. The percentage of patients who experienced a missed dose, lack of follow-up sputum examination, and interrupted treatment were 19.0%, 11.3%, and 9.2%, respectively. Patients aged 20-39 had a higher risk of missed dose [OR (95% CI): 2.302 (1.001-5.305)] and a lower risk of interrupted treatment [OR (95% CI): 0.278 (0.077-0.982)] than patients more than 60 years. Patients who were of Han ethnicity (OR [95% CI]: 0.524 [0.301-0.912]) received psychological support (OR [95% CI]: 0.379 [0.144-0.998]) from their family and had a lower risk of missed doses. Patients who had drug side effects had a higher risk of interrupted treatment (OR [95% CI]: 2.587 [1.237-5.412]). Patients who possessed higher knowledge had a lower risk of lack of follow-up sputum examination [OR (95% CI): 0.817 (0.673-0.991)]. The results of the qualitative study also reported that patients' poor TB knowledge was the main reason for their non-SRA behaviours.

CONCLUSIONS

Patient-centred strategies should be implemented to improve health literacy and strengthen psychological support. More effective case management should be designed and implemented based on different patient characteristics to improve adherence behaviours in further studies.

Reasons for loss to follow-up (LTFU) of pulmonary TB (PTB) patients: A qualitative study among Saharia, a particularly vulnerable tribal group of Madhya Pradesh, India

BACKGROUND

Loss to follow-up (LTFU) among pulmonary tuberculosis (PTB) patients is a significant challenge for TB control. However, there is a dearth of information about the factors leading to LTFU among marginalized communities. This study highlights the factors associated with LTFU in Saharia, a tribe of Madhya Pradesh having high tuberculosis (TB) prevalence.

METHODS

A qualitative study was carried out during January-April 2020 among twenty-two pulmonary TB patients, recorded as LTFU in NIKSHAY, with ten treatment supporters and ten patient's family members. Semi-structured personal interview tools were used to collect the information on the history of anti-tuberculosis treatment, adverse drug events (ADE), social cognitive, behaviors, myths, and misbeliefs. The interviews were transcribed and thematically analysed to examine underlying themes.

RESULTS

The study explored various social, behavioral factors leading to loss to follow-up among PTB patients. Drug side effects, alcoholism, social stigma, lack of awareness of the seriousness of the diseases and poor counseling are the main barriers to treatment adherence in this community.

CONCLUSIONS

The study highlights the need to address the issues related to LTFU during TB treatment. The enhanced efforts of treatment supporters, health staff, and family & community persons must motivate and support the patients.

Addressing tuberculosis through complex community-based socioeconomic interventions in low- and middle-income countries: A systematic realist review

The established relationship between poverty and tuberculosis has led to the implementation of complex socioeconomic interventions to address poverty as both a risk factor for and consequence of tuberculosis. However, limited research to date has examined the conditions that facilitate the successful implementation of these interventions. We conducted a systematic realist review to examine how complex socioeconomic interventions for tuberculosis treatment and care were defined, implemented, and evaluated in low- and middle-income countries. We used a systematic search to identify published work that implemented complex socioeconomic interventions for tuberculosis, followed by a realist analysis informed by existing programme theories. From a total of 2825 collected records, 36 peer-reviewed articles and 17 grey literature reports were included in this review. The realist analysis identified three main contexts (sociopolitical and cultural; relational and interpersonal; operational and administrative) and ten mechanisms that facilitated successful implementation of interventions. Overall, this review highlights the importance of political commitment in shaping sustainable programme delivery, the role of healthcare and community-based provider training in creating patient-centred treatment environments, and the opportunity to leverage operational research for evidence-based decision making to address the socioeconomic needs of tuberculosis patients experiencing poverty.

Understanding pretreatment loss to follow-up of tuberculosis patients: an explanatory qualitative study in Chennai, India

Introduction

Pretreatment loss to follow-up (PTLFU)-dropout of patients after diagnosis but before treatment registration-is a major gap in tuberculosis (TB) care in India and globally. Patient and healthcare worker (HCW) perspectives are critical for developing interventions to reduce PTLFU.

Methods

We tracked smear-positive TB patients diagnosed via sputum microscopy from 22 diagnostic centres in Chennai, one of India's largest cities. Patients who did not start therapy within 14 days, or who died or were lost to follow-up before official treatment registration, were classified as PTLFU cases. We conducted qualitative interviews with trackable patients, or family members of patients who had died. We conducted focus group discussions (FGDs) with HCWs involved in TB care. Interview and FGD transcripts were coded and analysed with Dedoose software to identify key themes. We created categories into which themes clustered and identified relationships among thematic categories to develop an explanatory model for PTLFU.

Results

We conducted six FGDs comprising 53 HCWs and 33 individual patient or family member interviews. Themes clustered into five categories. Examining relationships among categories revealed two pathways leading to PTLFU as part of an explanatory model. In the first pathway, administrative and organisational health system barriers-including the complexity of navigating the system, healthcare worker absenteeism and infrastructure failures-resulted in patients feeling frustration or resignation, leading to disengagement from care. In turn, HCWs faced work constraints that contributed to many of these health system barriers for patients. In the second pathway, negative HCW attitudes and behaviours contributed to patients distrusting the health system, resulting in refusal of care.

Conclusion

Health system barriers contribute to PTLFU directly and by amplifying patient-related challenges to engaging in care. Interventions should focus on removing administrative hurdles patients face in the health system, improving quality of the HCW-patient interaction and alleviating constraints preventing HCWs from providing patient-centred care.

User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review

BACKGROUND

Tuberculosis affected 2.7 million people in India in 2017. The Revised National TB Control Programme has achieved milestones in coverage, however quality of TB care remains highly variable and often poor, with significant gaps in provider knowledge, practices, and patients consistently lost to follow-up. These quality gaps are largely informed by studies on provider practices or objective chart abstractions and case data. Per the knowledge of the author, no review has been conducted on first-hand patient perspectives on the quality of TB care they receive. This mixed-methods literature review aims to synthesize evidence on user-experience and patient satisfaction with TB care in India and inform areas for service quality improvement.

METHODS

Five medical databases, including PubMed, EMBASE, Global Health (Ovid), Web of Science, and CINAHL were searched for empirical studies on patient perspectives on TB health services published between January 1st, 2000 to December 31st, 2017. Studies in English with adult patients with any form of TB in the public or private health system were included. Studies prior to entering the health system, on distance to health facilities and cost were excluded. Seven Indian journals were hand searched and a grey literature search was conducted in GoogleScholar. Studies were assessed for methodological quality and thematic analysis was conducted by categorizing data using NVivo 12.

RESULTS

A total of 498 studies were screened, of which 23 met the inclusion criteria. 16 supplementary studies were identified from Indian journals and grey literature. Of the 39 total studies included most were quantitative (29; 74%), based in South India (17; 44%) and focused on drug-sensitive TB patients (19; 49%) within the public health system (25; 64%). Data collection methods were highly heterogenous which limited synthesis and comparisons across population demographics, health sectors, or regions. Overall quantitative patient satisfaction measured in seven studies was high. Two major themes identified were provider-related factors (n = 26 studies) and convenience (n = 25), and six minor themes were supplies and equipment availability (n = 12), confidence (n = 10), information and communication (n = 10), waiting time (n = 8), stigma (n = 4), and confidentiality (n = 4). Each reported positive and negative user-experiences. Most significantly, DOTS did not fit the daily needs and obligations of many patients, particularly due to conflicts with employment and frequency of visits; while positive provider support, information, and flexibility helped patients adhere to treatment.

CONCLUSION

Although quantitative patient satisfaction was found to be high, data were not collected using robust, validated tools. Qualitative and quantitative user-experiences in each theme were variable, making them both barriers and facilitators of good quality TB care. Poor user-experiences were often responsible for patients interrupting treatment or dropping out of TB care. Patient-centeredness, or user-friendliness of TB care can be improved by introducing individualized or flexible DOTS that is responsive to user circumstances and needs. User-experience data should be systematically collected using a standardized, national tool for identification of specific bottlenecks and successes in quality of TB care from the patients' perspective.

Adherence to isoniazid preventive therapy among child contacts in Rwanda: A mixed-methods study

BACKGROUND

The World Health Organization recommends isoniazid preventive therapy (IPT) for six months for child contacts without tuberculosis (TB), who are exposed to an adult with active TB. The effectiveness of IPT depends on 80% or greater adherence to medication. In the current study, we assessed IPT adherence and explored barriers to and facilitators of adherence among eligible child contacts in Kigali, Rwanda.

METHODS

A mixed method study design was used to prospectively assess adherence to IPT among eligible child contacts and its associated factors through a quantitative, observational cohort study, and to explore barriers to and facilitators of adherence to IPT through a descriptive qualitative study.

RESULTS

Of the 84 child contacts who started IPT, 74 (88%) had complete adherence and ten (12%) had incomplete adherence. There were no factors (individual characteristics of index cases, households and or health facility characteristics) found to be significantly associated with IPT adherence in the bivariate and multivariate analysis. In the qualitative analysis, we identified factors relating to parents/caregivers, disease, household and health-care providers as major themes determining IPT adherence.

CONCLUSION

There was a high rate of IPT completion in this cohort of eligible child contacts living in Kigali. However, structural factors (poverty and relocation) were found to be the main barriers to IPT adherence that could be addressed by health-care providers.

Predictors of tuberculosis treatment outcomes among a retrospective cohort in rural, Central India

Introduction

Programmatic design affects access to healthcare and can influence tuberculosis treatment outcomes. Potential predictors of tuberculosis treatment outcomes in one rural Indian setting were examined to improve outcomes with a focus on access to care.

Methods

Routinely collected tuberculosis treatment data from Jan Swasthya Sahyog, a community based healthcare system in rural Chhattisgarh, India were examined from 2003–2015. Predictors were analyzed for associations with death, loss to follow-up or failure in multivariable logistic regression models. The effect of distance from treatment on outcomes was graphed and Pearson's correlation coefficients (r²) calculated. Descriptive time to event analyses were performed for all deaths and loss to follow-up from January 2010 to September 2015.

Results

4979 patients with active TB were treated during the study period. Patients were mostly male, malnourished, diagnosed with pulmonary disease and many travelled lengthy distances. Positive treatment outcomes improved from 55% to 80% from 2003 to 2015 for all patients though positive treatment outcomes have been above 80% in the primary care setting since 2012. The annual case fatality rate was 4.4% with small yearly variation.Gender and site of treatment (primary versus secondary care facility) and also season of treatment initiation and travel time to care best predicted outcomes in both the complete model and model which included only patients with initial BMI data. No differences were found between primary and secondary care patients for initial BMI, percentage of sputum positivity among those with pulmonary disease and grade of sputum positivity among the sputum positive. Those who traveled the furthest to access care achieved the worst outcomes during the summer and, to a lesser degree, the monsoon. Distance from care was associated with treatment outcomes in a dose-response manner out to substantial distances. From 2010 to 2015, most patients who died or were lost to follow-up did so in the first week of treatment.

Conclusions

The provision of care through local facilities improves the treatment of tuberculosis in rural India. Interventions addressing death or loss to follow-up should focus on the newly diagnosed. Rural Indian physicians should be aware of how access issues affect TB treatment outcomes.

Enhancing tuberculosis patient detection and care through community volunteers in the urban poor, The Philippines

Setting: The Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association Philippines is a local non-governmental organisation (NGO) established in 2008 to improve access to tuberculosis (TB) services. Community health volunteers (CHVs) from NGO referring facilities were engaged to assist in local TB control activities. Objective: To describe the activities of the CHVs and the barriers experienced by patients with presumptive TB in seeking health care to treatment as documented on a master list, and to identify the CHVs' challenges in community TB care implementation. Design: This was a retrospective evaluation with a non-experimental design reviewing the presumptive TB master list and TB reports and conducting a free discussion session (FDS) in 2012. Results: Of the 78% (281/362) of referred presumptive TB patients who accessed a DOTS facility, 69% (194/281) underwent a diagnostic examination and 42% (81/194) were diagnosed with active TB. Of the 93% (75/81) initiated on treatment, 92% (69/75) were successfully treated. The CHVs contributed approximately 3% (75/2534) to the total TB cases diagnosed at the DOTS facilities. In the FDS, barriers evoked in seeking health care for treatment were transfer of residence and lack of interest in seeking a consultation. In 2012, the CHV attrition rate was 55% (80/145). Conclusion: The CHVs assisted in enhancing access to TB care and case detection. Sustainability of the CHVs' efforts should be explored to retain them in the programme.

Genetic diversity & drug sensitivity profiles of Mycobacterium tuberculosis isolates from two slums of Jaipur city, Rajasthan, India

Background & objectives:

Slums are considered as hotspots of tuberculosis (TB). The study of genetic diversity and drug susceptibility profile of Mycobacterium tuberculosis (MTB) will help understand the transmission dynamics and can be used for better prevention and control of the disease. The aim of this study was to determine the drug susceptibility profiles and genetic diversity using the random amplified polymorphic DNA (RAPD) and mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU VNTR) of MTB isolates from sputum samples of pulmonary TB patients residing in the two slums of Jaipur city in Rajasthan, India.

Methods:

Sputum samples collected from pulmonary TB patients, their contacts and suspects during 2010-2012 were processed for microscopy and mycobacterial culture. Drug susceptibility testing was done by one per cent indirect proportion method on Lowenstein–Jensen medium for first-line anti-TB drugs rifampicin, isoniazid, ethambutol and streptomycin. MTB DNA was extracted by physicochemical method, and DNA fingerprinting was done by RAPD and MIRU VNTR analysis.

Results:

Among 175 sputum samples collected, 75 were positive (43.8%) for acid-fast bacilli, 83 for MTB culture and four were contaminated. Fifty two isolates (62.7%) were fully sensitive to four drugs, and five (6%) were multidrug resistant (MDR). RAPD analysis of 81 isolates revealed six clusters containing 23 (28.4%) isolates, and 58 (71.6%) were unique. MIRU VNTR analysis clustered 20 (24.7%) isolates, and 61 (75.3%) were unique.

Interpretation & conclusions:

About 62.7 per cent isolates from the sputum samples from slum areas were sensitive to four drugs; six per cent of isolates were MDR. Poly-resistance other than MDR was high (16%). About one-fourth isolates were clustered by either method. RAPD was rapid, less expensive but had low reproducibility. MIRU VNTR analysis could identify to greater extent the epidemiological link in the population studied.

Treatment compliance and noncompliance in psychoses

BACKGROUND

Compliance or noncompliance with treatment significantly influences course and outcome of psychiatric disorders. While noncompliance has been extensively researched, compliance has received less attention. The current study was conducted to elicit reasons for compliance and noncompliance in patients having psychoses attending psychiatric clinics.

MATERIALS AND METHODS

A total of 196 compliant and 150 noncompliant patients were interviewed using self-designed tools to elicit sociodemographic data, details of illness, and treatment. Factors contributing to compliance and noncompliance were grouped under illness-related, clinician-related, medication-related, family-related, and economic-related domains and compared.

RESULTS

Compliance was significantly more in females and middle- and high-socioeconomic status patients. They had less substance use, high physical comorbidity, high attendance in the outpatient department, and better remission. Clinician-related, family-related, and medication-related domains were contributing more to compliance whereas illness-related and economic-related domains seemed to have more bearing on noncompliance.

CONCLUSIONS

Compliance and noncompliance are determined multidimensionally. Domains related to clinician, family, and medications have to be reinforced to enhance compliance. Illness-related and economic domains have to be resolved to reduce noncompliance.

Effectiveness of a community-based observation of anti-tuberculosis treatment in Bangalore City, India, 2010-2011

SETTING

The Revised National Tuberculosis Control Programme in an urban setting of Bangalore City, India.

OBJECTIVES

To compare treatment outcomes and smear conversion rates among new smear-positive tuberculosis (TB) patients undergoing treatment administered by community directly observed treatment (DOT) providers with those undergoing treatment administered by institutional DOT providers in Bangalore City in 2010-2011.

METHOD

Cohort study of routine data recorded from treatment cards of TB patients undergoing treatment under the public health services from 1 October 2010 to 30 September 2011.

RESULT

Treatment records of 1864 new smear-positive TB patients registered during this period were evaluated. Among those evaluated, 604 (32%) had been administered treatment by community DOT providers and the remainder by institutional DOT providers. The treatment success rate in those undergoing community DOT was 93% (n = 564) and that of those undergoing institutional DOT was 75% (n = 951; RR 1.23, 95%CI 1.19-1.28). The sputum smear conversion rate of patients who underwent community DOT was 92% and that of those who underwent institutional DOT was 71% at the end of 2 months.

CONCLUSION

We conclude that community DOT for treatment supervision of TB patients is more effective than institutional DOT and that it should be reinforced.

Perspectives of Patients, Doctors and Medical Students at a Public University Hospital in Rio de Janeiro Regarding Tuberculosis and Therapeutic Adherence

Introduction

The World Health Organization (WHO) identifies 8.7 million new cases of tuberculosis (TB) annually around the world. The unfavorable outcomes of TB treatment prevent the achievement of the WHO’s cure target.

Goal

To evaluate existing intersections in the conceptions relative to the knowledge of TB, the experience of the illness and the treatment.

Methods

Doctors, medical students and patients were selected from a public university in Rio de Janeiro, Brazil, from 2011 to 2013. The data were obtained by semi-structured individual and focus group interviews, participant observation and a field journal. The inclusion of patients was interrupted due to saturation, and the inclusion of doctors and medical students stopped due to exhaustion. The theoretical background included symbolic Interactionism, and the analysis used rounded Theory. The analysis prioritized the actions/interactions axis.

Results

Twenty-three patients with pulmonary TB, seven doctors and 15 medical students were included. In the interviews, themes such as stigma, self-segregation, and difficulties in assistance emerged, in addition to defense mechanisms such as denial, rationalization, isolation and other mental mechanisms, including guilt, accountability and concealment of the disease. Aspects related to the assistance strategy, the social support network, bonding with the healthcare staff and the doctor-patient relationship were highlighted as adherence enablers. Doctors and students recommended an expansion of the theoretical and practical instruction on TB during medical students’ education. The existence of health programs and policies was mentioned as a potential enabler of adherence.

Conclusion

The main concepts identified were the stigma, self-segregation, guilt, responsibility, concealment and emotional repercussions. In relation to the facilitation of therapeutic adherence, the concepts identified were the bonds with healthcare staff, the doctor-patient relationship, assistance and educational health strategies.

Determinants of non adherence to tuberculosis treatment in Argentina: barriers related to access to treatment

OBJECTIVE: To identify the association between non-adherence to tuberculosis treatment and access to treatment. METHODS: A cross-sectional study was carried out in the Metropolitan Area of Buenos Aires, Argentina. One hundred twenty three patients notified in 2007 (38 non adherent and 85 adherents) were interviewed regarding the health care process and socio-demographic characteristics. Factors associated to non-adherence were assessed through logistic regression analysis. RESULTS: An increased risk of non-adherence with to treatment was found in male patients (OR = 2.8; 95%CI 1.2 - 6.7), patients who had medical check-ups at hospitals (OR = 3.4; 95%CI 1.1 - 10.0) and those who had difficulties with transportation costs (OR = 2.5; 95%CI 1.1 - 5.9). CONCLUSION: Risk of non-adherence increases as a result of economic barriers in accessing health care facilities. Decentralization of treatment to primary health care centers and social protection measures for patients should be considered as priorities for disease control strategies in order to lessen the impact of those barriers on adherence to treatment.

[Using the notion of vulnerability in the production of knowledge about tuberculosis: integrative review]

OBJECTIVE

to identify how the notion of vulnerability is used in national and international scientific publications that address the problem of tuberculosis.

METHOD

an integrative review of literature published in the databases of the Biblioteca Virtual em Saúde, the United States National Library of Medicine and the Biblioteca Digital Brasileira de Teses e Dissertações, considering the descriptors Tuberculosis and Vulnerability in Portuguese and English.

RESULTS

we selected fifty-eight studies published between 1992 and February 2014, which resulted in three categories of analysis. CONCLUSION the link between tuberculosis and the notion of vulnerability has not been sufficiently consolidated in national and international literature. This creates an obstacle for the achievement of the epistemological transformations and pragmatic measures that are required to obtain better results from interventions in the field.

Prevalence and factors associated with tuberculosis treatment outcome among hazardous or harmful alcohol users in public primary health care in South Africa

BACKGROUND

Tuberculosis (TB) remains a chronic infectious disease with high morbidity and mortality.

OBJECTIVE

The aim of this study was to assess the prevalence and associated factors of tuberculosis treatment failure, death and default among hazardous or harmful alcohol users.

METHOD

We conducted a prospective study with TB patients in 40 public health clinics in three districts in South Africa. All consecutively new tuberculosis and retreatment patients presenting at the 40 primary health care facilities with hazardous or harmful alcohol use were included in this study. Logistic regression was used to assess determinants of TB treatment failure, death and default.

RESULTS

The findings of our study showed that 70% of TB patients were either cured or had completed their TB treatment by the end of 6 months. In multivariate analysis participants living in a shack or traditional housing (Odds Ratio=OR: 0.63, Confidence Interval=CI: 0.45-0.89), being a TB retreatment patient (OR: 1.61, CI: 1.15-2.26) and residing in the eThekwini district (OR: 1.82, CI: 1.27-2.58) were significant predictors of treatment failure, death and default.

CONCLUSION

A high rate of treatment failure, death and default were found in the TB patients. Several factors were identified that can guide interventions for the prevention of treatment failure, death and default.

Health workers' performance in the implementation of Patient Centred Tuberculosis Treatment (PCT) strategy under programmatic conditions in Tanzania: a cross sectional study

Background

Patient Centred Tuberculosis Treatment (PCT) is a promising treatment delivery strategy for Mycobacterium tuberculosis (TB). It aims to improve adherence to treatment by giving patients the choice of having drug intake supervised at the health facility by a medical professional or at home by a supporter of their choice.

Methods

A cross-sectional survey was undertaken in three districts of Tanzania during October 2007, one year after PCT was rolled out nationally. Semi-structured questionnaires were used to assess whether key elements of the PCT approach were being implemented, to evaluate supporters’ knowledge, to capture opinions on factors contributing to treatment completion, and to assess how treatment completion was measured. Transcripts from open-ended responses were analysed using framework analysis.

Results

Interviews were conducted with 127 TB patients, 107 treatment supporters and 70 health workers. In total, 25.2% of TB patients were not given a choice about the place of treatment by health workers, and only 13.7% of those given a choice reported that they were given adequate time to make their decision. Only 24.3% of treatment supporters confirmed that they were instructed how to complete patients’ treatment cards. Proper health education was the factor most frequently reported by health workers as favouring successful completion of TB treatment (45.7%). The majority of health workers (68.6%) said they checked returned blister packs to verify whether patients had taken their treatment, but only 20.0% checked patients’ treatment cards.

Conclusions

The provision of choice of treatment location, information on treatment, and guidance for treatment supporters need to be improved. There is a requirement for regular re-training of health workers with effective supportive supervision if successful implementation of the PCT approach is to be sustained.

Patient views on determinants of compliance with tuberculosis treatment in the eastern cape, South Africa: an application of q-methodology

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'.

Sputum completion and conversion rates after intensive phase of tuberculosis treatment: an assessment of the Rwandan control program

BACKGROUND

In Rwanda tuberculosis (TB) is one of the major health problems. To contribute to an improved performance of the Rwandan National TB Control Program, we conducted a study with the following objectives: (1) to assess the completion rate of sputum smear examinations at the end of the intensive phase of TB treatment; (2) to assess the sputum conversion rate (SCR); (3) to assess associations between smear completion rate or SCR with key health facility characteristics.

METHODS

TB registers in 89 health facilities in five provinces were reviewed. Data of new and retreatment smear-positive pulmonary TB (PTB+) cases registered between January and June 2006 were included in the study. Data on key characteristics of the selected health facilities were also collected.

RESULTS

Among 1509 new PTB + cases, 32 (2.1%) had died by 2 months, and 178 (11.8%) had been transferred-out. Among the remaining 1299 patients, a smear examination at month 2 was done in 1039 (smear completion rate 80.0%). Among these 1039, 852 (82.0%) had become smear-negative. The smear completion rate and SCR varied considerably between health facilities. A high number of new PTB cases at a health facility was the only significant predictor of a low completion rate, while the only independent factor associated with low sputum conversion rates was rural (vs. urban) location of the health facility.

CONCLUSIONS

In Rwanda, too few patients get a smear examination after 2 months of TB treatment; the SCR among those with smear results was adequate at 82%. A high number of new TB patients at a health facility was a significant predictor of a low completion rate. The national TB control program should design strategies to improve completion rates.

Drug-resistant tuberculosis in Mumbai, India: An agenda for operations research

Operations research (OR) is well established in India and is also a prominent feature of the global and local agendas for tuberculosis (TB) control. India accounts for a quarter of the global burden of TB and of new cases. Multidrug-resistant TB is a significant problem in Mumbai, India's most populous city, and there have been recent reports of totally resistant TB. Much thought has been given to the role of OR in addressing programmatic challenges, by both international partnerships and India's Revised National TB Control Programme. We attempt to summarize the major challenges to TB control in Mumbai, with an emphasis on drug resistance. Specific challenges include diagnosis of TB and defining cure, detecting drug resistant TB, multiple sources of health care in the private, public and informal sectors, co-infection with human immunodeficiency virus (HIV) and a concurrent epidemic of non-communicable diseases, suboptimal prescribing practices, and infection control. We propose a local agenda for OR: modeling the effects of newer technologies, active case detection, and changes in timing of activities, and mapping hotspots and contact networks; modeling the effects of drug control, changing the balance of ambulatory and inpatient care, and adverse drug reactions; modeling the effects of integration of TB and HIV diagnosis and management, and preventive drug therapy; and modeling the effects of initiatives to improve infection control.

From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts

Background

Tuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment.

Objectives

To estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics.

Methods

A cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire.

Results

Of the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42–66%)] were determined to be taking treatment ‘under DOTS/RNTCP’. The remaining 278 [46% (95% CI: 34–57%)] were on treatment from ‘outside DOTS/RNTCP’ sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from ‘outside DOTS/RNTCP’ were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2–5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9–24.9).

Conclusions

This community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.

What 'outliers' tell us about missed opportunities for tuberculosis control: a cross-sectional study of patients in Mumbai, India

Background

India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96^th and 100^th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India.

Methods

We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95^th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays.

Results

Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme.

Conclusion

A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes.

A Qualitative Evaluation of the Information, Education, and Communication Component of the Tuberculosis Control Program in Delhi, India

Tuberculosis control programs have recognized and addressed those system components in which knowledge and behavior of the patient and the general population are key issues because they have a profound influence on the treatment-seeking behavior and completion of course of treatment. As a part of the Revised National Tuberculosis Control Program, the ongoing information, education, and communication (IEC) efforts in Delhi were further intensified in the form of a multipronged media campaign. The objectives of this study are to evaluate ( a) the impact of the campaign on awareness generation among the target audiences, ( b) their opinion for making the campaign more effective and suited to their needs, and ( c) perceptions of health personnel regarding the campaign. The study follows a descriptive cross-sectional design. The following qualitative methods were used: ( a) focus group discussions of patients and the general population, ( b) 3 key informant interviews of the health care personnel and a defaulter patient, and ( c) in-depth interviews of 20 DOTS (directly observed treatment, short course) providers. The study observed that ( a) different sociocultural segments of the population varied in terms of their observations of IEC messages, ( b) stigma associated with tuberculosis is widely prevalent despite having a campaign, and ( c) television was voted as the most effective IEC medium. IEC strategies should be tailor-made and suited to the needs of a particular subpopulation.

Delayed treatment of tuberculosis patients in rural areas of Yogyakarta province, Indonesia

Background

In year 2000, the entire population in Indonesia was 201 million and 57.6 percent of that was living in rural areas. This paper reports analyses that address to what extent the rural structure influence the way TB patients seek care prior to diagnosis by a DOTS facility.

Methods

We documented healthcare utilization pattern of smear positive TB patients prior to diagnosis and treatment by DOTS services (health centre, chest clinic, public and private hospital) in Yogyakarta province. We calculated the delay in treatment as the number of weeks between the onset of symptoms and the start of DOTS treatment. Statistical analysis was carried out with Epi Info version 3.3 (October 5, 2004).

Results

The only factor which was significantly associated with total delay was urban-rural setting (p = < 0.0001). The median total delay for TB patients in urban districts was 8 (1^st Quartile = 4; 3^rd Quartile = 12) weeks compared to 12 (1^st Quartile = 7; 3^rd Quartile = 23) weeks for patients in rural districts. Multivariate analysis suggested no confounding between individual factors and urban-rural setting remained as the main factor for total delay (p = < 0.0001). Primary health centre was the first choice provider for most (38.7%) of these TB patients. Urban-rural setting was also the only factor which was significantly associated with choice of first provider (p = 0.03).

Conclusion

Improving access to DOTS services in rural areas is an area of vital importance in aiming to make progress toward achieving TB control targets in Indonesia.

Conflicting accountabilities: Doctor's dilemma in TB control in rural India

OBJECTIVE

The aim of this study was to analyse how the implementation strategy of direct observed treatment short course (DOTS) has shaped and influenced patient-provider encounters in a district tuberculosis centre (DTC) in a rural district of India.

METHOD

Qualitative methods, combining observations and interviews, were carried out in a DTC focusing on the medical encounters between a TB doctor and his patients.

RESULTS

The findings showed that the TB doctor seemed to be working with a dilemma, defined as conflicting accountabilities, in the medical encounters. In an organization perceived as inefficient and resource-constrained, the doctor struggled to find a balance between meeting the obligations of the DOTS programme and meeting the needs and expectations of the patients. Strategies to deal with these conflicting accountabilities were identified as limiting patients' involvement, struggling to maintain authority, and transferring responsibility.

CONCLUSION

Professional involvement and patient participation were seen as part of a linked process in this study, and the importance of empowering doctors and health care workers who are implementing DOTS is emphasized. The development of DOTS guidelines needs to be based on the actual process of health care delivery, and staff empowering efforts should also include strengthening of public health care infrastructure.

Performance indicators of DOT at home for tuberculosis control in a large city, SP, Brazil

The study had the objective to analyze the performance of the health services that implement the Directly Observed Therapy at home for tuberculosis control. This study analyzed four Tuberculosis Control Programs, referred to as A, B, C, and D, using the following indicators: Resource use; Performance quickness; Monitoring medication administration; Time spent per home visit. Data were collected during visits to 47 patients receiving DOT at home. Resource use was higher in program B (91.3%); program A showed quicker performance (5.8) and more visits during which medication administration was monitored (77.4%); program C had the longest time spent per home visit (14.7 minutes) and program A the shortest (10.4 minutes). The best or worst performance numerically expresses how resources are being used and whether the observation of medication intake is being achieved.

In search of cyclooxygenase inhibitors, anti-Mycobacterium tuberculosis and anti-malarial drugs from Thai flora and microbes

Malaria continues to be a major infectious disease of the developing world and the problem is compounded not only by the emergence of drug resistant strains but also from a lack of a vaccine. The situation for tuberculosis (TB) infection is equally problematic. Once considered a "treatable" disease for which eradication was predicted, TB has re-emerged as highly lethal, multi-drug resistant strains after the outbreak of AIDS. Worldwide, the disease causes millions of deaths annually. Similarly, treatments for chronic inflammatory diseases such as arthritis have been impeded due to the potentially lethal side effects of the new and widely prescribed non-steroidal anti-inflammatory compounds. Thais have utilized bioresources from plants and some microorganisms for medicine for thousands of years. Because of the need for new drugs to fight malaria and TB, with radically different chemical structures and mode of actions other than existing drugs, efforts have been directed towards searching for new drugs from bioresources. This is also true for anti-inflammatories. Although Thailand is considered species-rich, only a small number of potential bioresources has been investigated. This article briefly describes the pathogenesis of 2 infectious diseases, malaria and TB, and modern medicines employed in chemotherapy. Diversities of Thai flora and fungi and their chemical constituents with antagonistic properties against these 2 diseases are described in detail. Similarly, anti-inflammatory compounds, mostly cyclooxygenase (COX) inhibitors, are also described herein to demonstrate the potential of Thai bioresources to provide a wide array of compounds for treatment of diseases of a different nature.

Patient adherence to tuberculosis treatment: a systematic review of qualitative research

BACKGROUND

Tuberculosis (TB) is a major contributor to the global burden of disease and has received considerable attention in recent years, particularly in low- and middle-income countries where it is closely associated with HIV/AIDS. Poor adherence to treatment is common despite various interventions aimed at improving treatment completion. Lack of a comprehensive and holistic understanding of barriers to and facilitators of, treatment adherence is currently a major obstacle to finding effective solutions. The aim of this systematic review of qualitative studies was to understand the factors considered important by patients, caregivers and health care providers in contributing to TB medication adherence.

METHODS AND FINDINGS

We searched 19 electronic databases (1966-February 2005) for qualitative studies on patients', caregivers', or health care providers' perceptions of adherence to preventive or curative TB treatment with the free text terms "Tuberculosis AND (adherence OR compliance OR concordance)". We supplemented our search with citation searches and by consulting experts. For included studies, study quality was assessed using a predetermined checklist and data were extracted independently onto a standard form. We then followed Noblit and Hare's method of meta-ethnography to synthesize the findings, using both reciprocal translation and line-of-argument synthesis. We screened 7,814 citations and selected 44 articles that met the prespecified inclusion criteria. The synthesis offers an overview of qualitative evidence derived from these multiple international studies. We identified eight major themes across the studies: organisation of treatment and care; interpretations of illness and wellness; the financial burden of treatment; knowledge, attitudes, and beliefs about treatment; law and immigration; personal characteristics and adherence behaviour; side effects; and family, community, and household support. Our interpretation of the themes across all studies produced a line-of-argument synthesis describing how four major factors interact to affect adherence to TB treatment: structural factors, including poverty and gender discrimination; the social context; health service factors; and personal factors. The findings of this study are limited by the quality and foci of the included studies.

CONCLUSIONS

Adherence to the long course of TB treatment is a complex, dynamic phenomenon with a wide range of factors impacting on treatment-taking behaviour. Patients' adherence to their medication regimens was influenced by the interaction of a number of these factors. The findings of our review could help inform the development of patient-centred interventions and of interventions to address structural barriers to treatment adherence.

A review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS?

BACKGROUND

Suboptimal treatment adherence remains a barrier to the control of many infectious diseases, including tuberculosis and HIV/AIDS, which contribute significantly to the global disease burden. However, few of the many interventions developed to address this issue explicitly draw on theories of health behaviour. Such theories could contribute to the design of more effective interventions to promote treatment adherence and to improving assessments of the transferability of these interventions across different health issues and settings.

METHODS

This paper reviews behaviour change theories applicable to long-term treatment adherence; assesses the evidence for their effectiveness in predicting behaviour change; and examines the implications of these findings for developing strategies to improve TB and HIV/AIDS medication adherence. We searched a number of electronic databases for theories of behaviour change. Eleven theories were examined.

RESULTS

Little empirical evidence was located on the effectiveness of these theories in promoting adherence. However, several models have the potential to both improve understanding of adherence behaviours and contribute to the design of more effective interventions to promote adherence to TB and HIV/AIDS medication.

CONCLUSION

Further research and analysis is needed urgently to determine which models might best improve adherence to long-term treatment regimens.

Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis

AIM

This paper reports the findings from a qualitative meta-synthesis concerning people with, or at risk of, tuberculosis, service providers and policymakers and their experiences and perceptions of tuberculosis and treatment.

BACKGROUND

Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves.

METHOD

Qualitative systematic review methods were used to search, screen, appraise and extract data thematic analysis was used to synthesize data from 1990 to 2002, and an update of literature to December 2005. Two questions were addressed: 'What does qualitative research tell us about the facilitators and barriers to accessing and complying with tuberculosis treatment?' and 'What does qualitative research tell us about the diverse results and effect sizes of the randomized controlled trials included in the Cochrane review?' Findings help explain the diverse trial results in a Cochrane systematic review of directly observed therapy and tuberculosis and consider implications for research, policy and practice.

FINDINGS

Five themes emerged from the 1990 to 2002 synthesis: socio-economic circumstances, material resources and individual agency; explanatory models and knowledge systems in relation to tuberculosis and its treatment; the experience of stigma and public discourses around tuberculosis; sanctions, incentives and support, and the social organization and social relationships of care. Two additional themes emerged from the 2005 update.

CONCLUSION

The qualitative meta-synthesis improved the relevance and scope of the Cochrane review of trials. The findings make a major contribution to the development of theory concerning global WHO-branded disease control and the practicality of local delivery to people.

Are intestinal helminths risk factors for developing active tuberculosis?

OBJECTIVES

To determine the prevalence of intestinal helminth infections in active tuberculosis patients and their healthy household contacts and to assess its association with active TB in an area endemic for both types of infections.

METHODS

Smear-positive pulmonary TB patients and healthy household contacts were tested for intestinal helminths using direct microscopy and the formol-ether concentration techniques. Three consecutive stool samples were examined before the start of TB chemotherapy. Sputum microscopy was done using the sodium hypochlorite concentration techniques. Participants were also tested for HIV by commercial sandwich enzyme linked immunosorbent assay.

RESULTS

The study population consisted of 230 smear-positive TB patients and 510 healthy household contacts. The prevalence of intestinal helminths was 71% in patients and 36% in controls. HIV seroprevalence was significantly higher in patients than in controls (46.7%vs. 11.6%, P < 0.001). Conditional logistic regression analysis showed a strong association between TB and intestinal helminth infection (OR = 4.2, 95% CI 2.7-5.9, P < 0.001), and between TB and HIV infection (OR = 7.8, 95% CI 4.8-12.6, P < 0.0001). The odds of being a TB patient increased with the number of helminth species per person: in individuals with mono-infection it was 4.3 (95% CI 2.8-6.8); in people infected with two species was 4.7 (95% CI 2.5-8.7), and in patients infected with three or more helminths was 12.2 (3.9-52.6).

CONCLUSION

Intestinal helminth infection may be one of the risk factors for the development of active pulmonary TB in addition to HIV infection. This finding may have important implications in the control of TB in helminth endemic areas of the world.

An exploration of the social stigma of tuberculosis in five “municipios” of Nicaragua to reflect on local interventions

OBJECTIVE

The social stigma of tuberculosis is much less studied than those of other diseases such as AIDS or mental problems. However, it has important implications on the affected person's well being and on the epidemic's control. Our study aims at exploring this social stigma in five local health systems of Nicaragua, prior to implementing interventions to reduce it.

METHODS

Through in-depth interviews and focus groups involving stakeholders in the care of people affected by tuberculosis (PATBs), we analysed interactions between PATBs and family members, first line government health services' personnel, and community members.

RESULTS

According to our results, the interaction between stakeholders and PATBs can be described as the intersection between two sets of contradictory feelings and attitudes: (a) feelings of affection and supportive attitudes toward PATBs opposed to the fear of being infected or that PATBs will infect others and, (b) confidence in PATBs considered to be unlucky opposed to mistrust of PATBs considered to be negligent. PATBs react against this mainly by hiding their condition which leads them to a, loss of confidence and depression. This intricate group of feelings and attitudes is influenced by two sets of determinants related to domination and power between stakeholders and issues of knowledge and information.

CONCLUSION

Analysing tuberculosis-related social stigma as a social process enabled us to better understand some key social structural factors of health care system's organisation and identify locally acceptable interventions to reduce such stigma. The fact of analysing, in a more thorough study, some interventions in the currently changing social structural context of health care systems in Nicaragua will give us a better insight into the relevance of our analysis and the interventions' effectiveness in reducing the social stigma of tuberculosis.

Tuberculosis patient adherence to direct observation: results of a social study in Pakistan

A randomized controlled trial was carried out in Pakistan in 1999 to establish the effectiveness of the direct observation component of DOTS programmes. It found no significant differences in cure rates for patients directly observed by health facility workers, community health workers or by family members, as compared with the control group who had self-administered treatment. This paper reports on the social studies which were carried out during and after this trial, to explain these results. They consisted of a survey of all patients (64% response rate); in-depth interviews with a smaller sample of different types of patients; and focus group discussions with patients and providers. One finding was that of the 32 in-depth interview patients, 13 (mainly from the health facility observation group) failed to comply with their allocated DOT approach during the trial, citing the inconvenience of the method of observation. Another finding was that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation). This may be one of the reasons why there was no overall benefit from direct observation in the trial. Provider attitudes were also poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their, rather than patients', schedules. The article concludes that direct observation, if used, should be flexible and convenient, whether at a health facility close to the patient's home or in the community. The emphasis should shift in practice from tablet watching towards treatment support, together with education and other adherence measures.

Tuberculosis control in resource-poor countries: have we reached the limits of the universal paradigm?

The aim of TB control is to break the cycle of transmission by treating TB cases as early and efficiently as possible. In its efforts to promote a model of worldwide TB control, WHO defined specific targets and launched the 'Directly Observed Therapy, Short-course' (DOTS) strategy as the main tool to reach them. However, the diversity of patients' attitudes towards the disease and the extreme variability of access to care, especially in resource-poor countries, are amongst the many factors of social context that profoundly affect the ability of control programmes to implement this policy effectively. There are multiple reports of TB control programmes using various types of intervention to promote adherence and enhance case-holding, but most of these interventions depend on external funding, which bring into question their long-term sustainability. In this paper, we address the problems related to operational variabilities in the implementation of the DOTS strategy in resource-poor countries and question the appropriateness of a universal paradigm for global TB control. This analysis is of particular importance as programmers consider using this model in the delivery of anti-retroviral therapies for the treatment of HIV in resource-limited settings.

Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India

The Revised National Tuberculosis Control Programme (RNTCP), which incorporated the WHO DOTS strategy was introduced in India in the mid-1990s. An operational research project was conducted between 1996 and 1998 to assess the needs and perspectives of patients and providers in two chest clinics in Delhi, Moti Nagar and Nehru Nagar, during the introduction of the new strategy. This paper reports on the findings of the project, concentrating on information collected from 40 in-depth interviews with patient defaulters and from non-participant observations in clinics and directly observed treatment centres. In Moti Nagar chest clinic, 117 of 1786 (6.5%) patients and 195 of 1890 (10%) patients in Nehru Nagar left care before their treatment was complete. It was argued that the reasons for default stem from a poor correlation between patient and programme needs and priorities, and from particular characteristics of the disease and its treatment. Patient needs that were not met by the health system included convenient clinic timings, arrangements for the provision for treatment in the event of a family emergency and provision for complicated cases like alcoholics. The problems facing the provider were poor interpersonal communication with the health staff, lack of attention and support at the clinic, difficulty for patients to re-enter the system if they missed treatment and, in certain areas, long distances to the clinic. Problems related to diseases were inability of the staff to deal with drug side-effects, and patients' conception of equating well-being with cure. Simple, practical measures could improve the provision of tuberculosis (TB) treatment: more flexible hours, allowances for poor patients to reach the clinics and training health care staff for respectful communication and monitoring drug side-effects. The findings indicate a need to rethink the label of 'defaulter' often given to the patients. The important areas for future operational research is also highlighted.