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Bhatnagar H. User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review. J Clin Tuberc Other Mycobact Dis 2019; 17:100127. [PMID: 31788569 PMCID: PMC6880015 DOI: 10.1016/j.jctube.2019.100127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Campbell JI, Eyal N, Musiimenta A, Burns B, Natukunda S, Musinguzi N, Haberer JE. Ugandan Study Participants Experience Electronic Monitoring of Antiretroviral Therapy Adherence as Welcomed Pressure to Adhere. AIDS Behav 2018; 22:3363-3372. [PMID: 29926301 PMCID: PMC6309333 DOI: 10.1007/s10461-018-2200-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Many new technologies monitor patients' and study participants' medical adherence. Some have cautioned that these devices transgress personal autonomy and ethics. But do they? This qualitative study explored how Ugandan study participants perceive the effect of electronic monitoring of their adherence to antiretroviral therapy (ART) on their freedoms to be non-adherent and pursue other activities that monitoring may inadvertently expose. Between August 2014 and June 2015, we interviewed 60 Ugandans living with HIV and enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) study, a longitudinal, observational study involving electronic adherence monitors (EAMs) to assess ART adherence. We also interviewed 6 UARTO research assistants. Both direct and indirect content analysis were used to interpret interview transcripts. We found that monitoring created a sense of pressure to adhere to ART, which some participants described as "forcing" them to adhere. However, even participants who felt that monitoring forced them to take medications perceived using the EAM as conducive to their fundamental goal of high ART adherence. Overall, even if monitoring may have limited participants' effective freedom to be non-adherent, participants welcomed any such effect. No participant rejected the EAM on the grounds that it would limit that effective freedom. Reports that monitoring altered behaviors unrelated to pill-taking were rare. Researchers should continue to be vigilant about the ways in which behavioral health monitoring affects autonomy, but should also recognize that even autonomy-limiting monitoring strategies may enable participants to achieve their own goals.
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Affiliation(s)
- Jeffrey I Campbell
- Department of Pediatrics, Boston Medical Center, and Boston Children's Hospital, One Boston Medical Center Pl, Dowling 3rd Floor, Boston, MA, 02118, USA.
| | - Nir Eyal
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Bojorquez I, Salazar I, Garfein RS, Cerecer P, Rodwell TC. Surveillance or support: The experience of direct observation during tuberculosis treatment. Glob Public Health 2018; 13:804-818. [PMID: 27748157 PMCID: PMC5392434 DOI: 10.1080/17441692.2016.1240823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Directly observed therapy (DOT) is a cornerstone of tuberculosis (TB) control. DOT has been criticised as paternalistic, but it has also been argued that the interaction with healthcare workers (HWs) can be a source of support for patients. We explored the experience of patients in antituberculosis treatment, with the aim of understanding the balance between surveillance and support from the recipient's point of view. We interviewed 27 patients in Tijuana, Mexico, employing narrative analysis to understand how participants made sense of their illness and their experience of DOT. We found a core narrative of biographic disruption and self-reconstruction, in which HWs helped participants to attribute a less negative meaning to TB. Interviewees accepted DOT's as necessary for other people to avoid treatment abandonment, but felt that in their case it was unnecessary. Only a few felt that DOT represented mistrust on the part of the HWs. We conclude that DOT can be a source of support when it is enacted in a patient-centred way. We discuss whether participants' lack of criticism of DOT is a case of adaptive preference, in the context of a power differential between patient and health system.
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Affiliation(s)
- Ietza Bojorquez
- a Department of Population Studies , El Colegio de la Frontera Norte , Tijuana , Mexico
| | - Irais Salazar
- b Academic direction, El Colegio de la Frontera Norte , Tijuana , Mexico
| | - Richard S Garfein
- c Division of Global Public Health , University of California , San Diego , CA , USA
- d Department of Medicine , University of California , San Diego , CA , USA
| | - Paris Cerecer
- e Secretaría de Salud de Baja California , Tijuana , Mexico
| | - Timothy C Rodwell
- f Division of Pulmonary, Critical Care and Sleep Medicine , University of California , San Diego , CA , USA
- g Department of Medicine , University of California , San Diego , CA , USA
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Abstract
The goals of this article are: (i) to understand how individual characteristics affect the likelihood of patients defaulting their pulmonary tuberculosis (PTB) treatment regimens; (ii) to quantify the predictive capacity of these risk factors; and (iii) to quantify and map spatial variation in the risk of defaulting. We used logistic regression models and generalized additive models with a spatial component to determine the odds of default across continental Portugal. We focused on new PTB cases, diagnosed between 2000 and 2013, and included some individual information (sex, age, residence area, alcohol abuse, intravenous drug use, homelessness, HIV, imprisonment status). We found that the global default rate was 4·88%, higher in individuals with well-known risk profiles (males, immigrants, HIV positive, homeless, prisoners, alcohol and drug users). Of specific epidemiological interest was that our geographical analysis found that Portugal's main urban areas (the two biggest cities) and one tourist region have higher default rates compared to the rest of the country, after adjusting for the previously mentioneded risk factors. The challenge of treatment defaulting, either due to other individual non-measured characteristics, healthcare system failure or patient recalcitrance requires further analysis in the spatio-temporal domain. Our findings suggest the presence of significant within-country variation in the risk of defaulting that cannot be explained by these classical individual risk factors alone. The methods we advocate are simple to implement and could easily be applied to other diseases.
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Yin J, Yuan J, Hu Y, Wei X. Association between Directly Observed Therapy and Treatment Outcomes in Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0150511. [PMID: 26930287 PMCID: PMC4773051 DOI: 10.1371/journal.pone.0150511] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 02/14/2016] [Indexed: 11/30/2022] Open
Abstract
Background Multidrug-resistant tuberculosis (MDR-TB) represents a major obstacle towards successful TB control. Directly observed therapy (DOT) was recommended by WHO to improve adherence and treatment outcomes of MDR-TB patients, however, the effectiveness of DOT on treatment outcomes of MDR-TB patients was mixed in previous studies. We conducted this systematic review and meta-analysis to assess the association between DOT and treatment outcomes and to examine the impact of different DOT providers and DOT locations on successful treatment outcomes in MDR-TB patients. Methods We searched studies published in English between January 1970 and December 2015 in major electronic databases. Two reviewers independently screened articles and extracted information of DOT, treatment success rate and other characteristics of studies. Random effects model was used to calculate the pooled treatment success rate and 95% confidence interval (CI). Sub-group analyses were conducted to access factors associated with successful treatment outcomes. Results A total of 31 articles 7,466 participants were included. Studies reporting full DOT (67.4%, 95% CI: 61.4–72.8%) had significantly higher pooled treatment success rates than those reporting self-administration therapy (46.9%, 95% CI: 41.4–52.4%). No statistically difference was found among DOT provided by healthcare providers (65.8%, 95% CI: 55.7–74.7%), family members (72.0%, 95% CI: 31.5–93.5%) and private DOT providers (69.5%, 95% CI: 57.0–79.7%); and neither did we find significantly difference on pooled treatment success rates between patients having health facility based DOT (70.5%, 95% CI: 61.5–78.1%) and home-based DOT (68.4%, 95% CI: 51.5–81.5%). Conclusion Providing DOT for a full course of treatment associated with a higher treatment success rate in MDR-TB patients.
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Affiliation(s)
- Jia Yin
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jinqiu Yuan
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yanhong Hu
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Xiaolin Wei
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Carter S, Entwistle V, Little M. Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions. Public Health 2015; 129:1021-9. [DOI: 10.1016/j.puhe.2015.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 01/15/2015] [Accepted: 03/12/2015] [Indexed: 01/03/2023]
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Sagbakken M, Frich JC, Bjune GA, Porter JDH. Ethical aspects of directly observed treatment for tuberculosis: a cross-cultural comparison. BMC Med Ethics 2013; 14:25. [PMID: 23819555 PMCID: PMC3702392 DOI: 10.1186/1472-6939-14-25] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 06/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective. DISCUSSION Research from Ethiopia and Norway demonstrates that the rigid enforcement of directly observed treatment conflicts with patient autonomy, dignity and integrity. The treatment practices, especially when imposed in its strictest forms, expose those who have Tuberculosis to extra burdens and costs. Socially disadvantaged groups, such as the homeless, those employed as day labourers and those lacking rights as employees, face the highest burdens. SUMMARY From an ethical standpoint, we argue that a rigid practice of directly observed treatment is difficult to justify, and that responsiveness to social determinants of Tuberculosis should become an integral part of the management of Tuberculosis.
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Affiliation(s)
- Mette Sagbakken
- Department of Nursing, Faculty of Health Sciences, Oslo and Akershus University College, PB 4, St. Olavs Plass, 0130, Oslo, Norway.
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Abstract
Discussions on the ethics and regulation of clinical research have a great deal to say about the responsibilities of investigators, sponsors, research institutions and institutional review boards, but very little about the responsibilities of research participants. In this article, we discuss the responsibilities of participants in clinical research. We argue that competent adult participants are responsible for complying with study requirements and fulfilling other obligations they undertake when they make an informed choice to enroll in a study. These responsibilities are based on duties related to promise-keeping, avoiding harm to one's self or others, beneficence and reciprocity. Investigators and research staff should inform participants about their responsibilities during the consent process, and should stress the importance of fulfilling study requirements. They should address any impediments to compliance, and they may provide participants with financial incentives for meeting study requirements. In very rare cases, coercive measures may be justified to prevent immanent harm to others resulting from non-compliance with study requirements.
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Affiliation(s)
- David B Resnik
- National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health (NIH), Research Triangle Park, NC 27709, USA.
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Fox GJ, Nhung NV, Sy DN, Lien LT, Cuong NK, Britton WJ, Marks GB. Contact investigation in households of patients with tuberculosis in Hanoi, Vietnam: a prospective cohort study. PLoS One 2012; 7:e49880. [PMID: 23166785 PMCID: PMC3499505 DOI: 10.1371/journal.pone.0049880] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 10/15/2012] [Indexed: 11/29/2022] Open
Abstract
Setting Existing tuberculosis control strategies in Vietnam are based on symptomatic patients attending health services for investigation. This approach has not resulted in substantial reductions in the prevalence of tuberculosis disease, despite the National Tuberculosis Program achieving high treatment completion rates. Alternative approaches are being considered. Objective To determine the feasibility and yield of contact investigation in households of patients with smear positive pulmonary tuberculosis among household members of tuberculosis patients in Hanoi, Vietnam. Methods Household contacts of patients with smear positive pulmonary tuberculosis were recruited at four urban and rural District Tuberculosis Units in Hanoi. Clinical and radiological screening was conducted at baseline, six months and 12 months. Sputum microscopy and culture was performed in contacts suspected of having tuberculosis. MIRU-VNTR molecular testing was used to compare the strains of patients and their contacts with disease. Results Among 545 household contacts of 212 patients, four were diagnosed with tuberculosis at baseline (prevalence 734 cases per 100,000 persons, 95% CI 17–1451) and one was diagnosed with tuberculosis during the subsequent 12 months after initial screening (incidence 180 cases per 100,000 person-years, 95% CI 44–131). Two of these cases were culture positive for M. tuberculosis and both had identical or near-identical MIRU-VNTR strain types. Conclusion Household contacts of patients with potentially infectious forms of tuberculosis have a high prevalence of disease. Household contact investigation is feasible in Vietnam. Further research is required to investigate its effectiveness.
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Affiliation(s)
- Gregory James Fox
- Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.
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Ahmed AI, Soliman SM, Awad LA. Validation of evidence-based clinical practice guideline: Nursing intervention for newly diagnosed pulmonary tuberculosis patients at community setting. ALEXANDRIA JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.ajme.2011.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Amel Ibrahim Ahmed
- Community Health Nursing Department, Faculty of Nursing-Mansoura University , Egypt
| | | | - Lamiaa Amin Awad
- Community Health Nursing Department, Faculty of Nursing-Mansoura University , Egypt
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Nackers F, Huerga H, Espié E, Aloo AO, Bastard M, Etard JF, Sitienei J, Varaine F, Chakaya J, Bonnet M. Adherence to self-administered tuberculosis treatment in a high HIV-prevalence setting: a cross-sectional survey in Homa Bay, Kenya. PLoS One 2012; 7:e32140. [PMID: 22427820 PMCID: PMC3299652 DOI: 10.1371/journal.pone.0032140] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 01/23/2012] [Indexed: 11/26/2022] Open
Abstract
Background Good adherence to treatment is crucial to control tuberculosis (TB). Efficiency and feasibility of directly observed therapy (DOT) under routine program conditions have been questioned. As an alternative, Médecins sans Frontières introduced self-administered therapy (SAT) in several TB programs. We aimed to measure adherence to TB treatment among patients receiving TB chemotherapy with fixed dose combination (FDC) under SAT at the Homa Bay district hospital (Kenya). A second objective was to compare the adherence agreement between different assessment tools. Methods We conducted a cross-sectional survey amongst a series of new TB patients receiving 6 months of standard TB chemotherapy with FDC under SAT. Adherence was assessed at home with urine testing for Isoniazid (INH), pill count, interviewer-administered questionnaire and visual analogue scale (VAS). Results In November 2008 and in June 2009, 212 of 279 eligible patients were assessed for adherence. Overall, 95.2% [95%CI: 91.3–97.7] of the patients reported not having missed a tablet in the last 4 days. On the VAS, complete adherence was estimated at 92.5% [95%CI: 88.0–95.6]. INH urine test was positive for 97.6% [95%CI: 94.6–99.2] of the patients. Pill count could be assessed among only 70% of the interviewed patients. Among them, it was complete for 82.3% [95%CI: 75.1–88.1]. Among the 212 surveyed patients, 193 (91.0%) were successfully treated (cured or treatment completed). The data suggest a fair agreement between the questionnaire and the INH urine test (k = 0.43) and between the questionnaire and the VAS (k = 0.40). Agreement was poor between the other adherence tools. Conclusion These results suggest that SAT, together with the FDC, allows achieving appropriate adherence to antituberculosis treatment in a high TB and HIV burden area. The use of a combination of a VAS and a questionnaire can be an adequate approach to monitor adherence to TB treatment in routine program conditions.
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Chen YC. Pursuing a less restrictive means to health equity. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:40-41. [PMID: 22548523 DOI: 10.1080/15265161.2012.665140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Yen-Chang Chen
- Australian National University, School of Philosophy, Canberra 2601, Australia.
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Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend 2011; 118:100-10. [PMID: 21515001 DOI: 10.1016/j.drugalcdep.2011.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 03/08/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. METHOD We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. RESULTS SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. CONCLUSIONS SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.
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Cheyette CM. Communitarianism and the ethics of communicable disease: some preliminary thoughts. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2011; 39:678-689. [PMID: 22084854 DOI: 10.1111/j.1748-720x.2011.00635.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Communicable diseases, especially those that are highly contagious, are on the rise and each of us, no matter who we are or where we live, is equally at risk of transmitting contagious diseases to others as we are of contracting such diseases from others. Because contagious diseases are as readily passed state-to-state as person-to-person, we all have a stake in every country's ability to enact effective infectious disease control policies, while policies grounded in shared values are more likely to gain widespread acceptance and thereby prove most effective. This paper suggests that principlism proved invaluable as an ethical framework for resolving hard medical cases and setting health care policy because it nicely "fits" dilemmas that arise in the context of the special relationship between doctors and patients or within family units. It then argues that communitarianism provides the better foundation for crafting infectious diseases control policies because contagious diseases, which often pass between perfect strangers, raise questions about the moral obligations we owe to (or are entitled to demand of) people with whom we share no "special" relationship. Accordingly, a socially embedded framework such as communitarianism may be a better fit for the more socially embedded ethical dilemmas of communicable diseases.
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Marais BJ, Raviglione MC, Donald PR, Harries AD, Kritski AL, Graham SM, El-Sadr WM, Harrington M, Churchyard G, Mwaba P, Sanne I, Kaufmann SHE, Whitty CJM, Atun R, Zumla A. Scale-up of services and research priorities for diagnosis, management, and control of tuberculosis: a call to action. Lancet 2010; 375:2179-91. [PMID: 20488521 DOI: 10.1016/s0140-6736(10)60554-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Millennium Development Goal target for tuberculosis control is to halt the spread of tuberculosis by 2015, and begin to reverse the worldwide incidence. After the introduction of standard control practices in 1995, 36 million people were cured and about 6 million deaths were averted. However, substantial scientific advances and innovative solutions are urgently needed together with creative new strategies. Strong international and national political commitment is essential. Urgent action is needed by national governments to fund their own programmes, and for the G8 countries and other donor governments and organisations to support governmental and non-governmental efforts. To foster the global need for urgent action to control the tuberculosis epidemic, The Lancet, in collaboration with the Stop TB Partnership, WHO, Global Fund to Fight AIDS, Tuberculosis and Malaria, and the experts participating in this Series, is launching The Lancet TB Observatory, which will assess and monitor progress in tuberculosis control and research, assess domestic and global financing, regularly disseminate information, and advocate for intensified efforts with stakeholders at all levels.
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Affiliation(s)
- Ben J Marais
- Department of Paediatrics and Child Health, Tygerberg Children's Hospital, Stellenbosch University, Tygerberg, South Africa.
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Ford N, Nachega JB, Engel ME, Mills EJ. Directly observed antiretroviral therapy: a systematic review and meta-analysis of randomised clinical trials. Lancet 2009; 374:2064-2071. [PMID: 19954833 DOI: 10.1016/s0140-6736(09)61671-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Directly observed therapy has been recommended to improve adherence for patients with HIV infection who are on highly active antiretroviral therapy, but the benefit and cost-effectiveness of this approach has not been established conclusively. We did a systematic review and meta-analysis of randomised trials of directly observed versus self-administered antiretroviral treatment. METHODS We did duplicate searches of databases (from inception to July 27, 2009), searchable websites of major HIV conferences (up to July, 2009), and lay publications and websites (March-July, 2009) to identify randomised trials assessing directly observed therapy to promote adherence to antiretroviral therapy in adults. Our primary outcome was virological suppression at study completion. We calculated relative risks (95% CIs), and pooled estimates using a random-effects method. FINDINGS 12 studies met our inclusion criteria; four of these were done in groups that were judged to be at high risk of poor adherence (drug users and homeless people). Ten studies reported on the primary outcome (n=1862 participants); we calculated a pooled relative risk of 1.04 (95% CI 0.91-1.20, p=0.55), and noted moderate heterogeneity between the studies (I(2)= 53.8%, 95% CI 0-75.7, p=0.0247) for directly observed versus self-administered treatment. INTERPRETATION Directly observed antiretroviral therapy seems to offer no benefit over self-administered treatment, which calls into question the use of such an approach to support adherence in the general patient population. FUNDING None.
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Affiliation(s)
- Nathan Ford
- Médecins Sans Frontières, Cape Town, Western Cape, South Africa.
| | - Jean B Nachega
- Department of Medicine and Centre for Infectious Diseases, Faculty of Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa; Department of International Health and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Department of Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Edward J Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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Abstract
As a result of increased interest in global health, more and more medical students and trainees from the 'developed world' are working and studying in the 'developing world'. However, while opportunities to do this important work increase, there has been insufficient development of ethical guidelines for students. It is often assumed that ethics training in developed world situations is applicable to health experiences globally. However, fundamental differences in both clinical and research settings necessitate an alternative paradigm of analysis. This article is intended for teachers who are responsible for preparing students prior to such experiences. A review of major ethical issues is presented, how they pertain to students, and a framework is outlined to help guide students in their work.
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Affiliation(s)
- Andrew D Pinto
- Department of Family and Community Medicine, University of Toronto, 410 Sherbourne Street, Toronto, Ontario, Canada.
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Abstract
This paper explains the ethical importance of infectious diseases, and reviews four major ethical issues associated with pandemic influenza: the obligation of individuals to avoid infecting others, healthcare workers' 'duty to treat', allocation of scarce resources, and coercive social distancing measures. In each case, ways in which the ethical issues turn on both philosophical and empirical questions are highlighted. The paper concludes that ethicists should play a greater role in identifying ethically important empirical questions, and that scientists should take the ethical as well as the scientific importance of such questions into consideration when choosing research projects.
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Affiliation(s)
- M J Selgelid
- Centre for Applied Philosophy and Public Ethics (CAPPE), The Australian National University, Canberra, Australia.
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Noyes J, Popay J. Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. J Adv Nurs 2007; 57:227-43. [PMID: 17233644 DOI: 10.1111/j.1365-2648.2006.04092.x] [Citation(s) in RCA: 212] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jane Noyes
- Cochrane Qualitative Research Methods Group University of Wales, Bangor, UK.
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Coker R, Thomas M, Lock K, Martin R. Detention and the evolving threat of tuberculosis: evidence, ethics, and law. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2007; 35:609-512. [PMID: 18076512 DOI: 10.1111/j.1748-720x.2007.00184.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The issue of detention as a public health control measure has attracted attention recently. This is because the threat of strains of tuberculosis that are resistant to a wider range of drugs has been identified, and there is renewed concern that public health is threatened. This paper considers whether involuntary detention is justified where voluntary measures have failed or where a patient poses a danger, albeit uncertain, to the public. We discuss the need for strengthening evidence-based assessments of public health risk and suggest that we should reflect more profoundly on the philosophical foundations upon which our policies and practices are grounded.
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Affiliation(s)
- Richard Coker
- Department of Public Health & Policy at the London School of Hygiene and Tropical Medicine
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Abstract
Singh and colleagues discuss the threat to regional and global public health posed by XDR-TB in KwaZulu-Natal, and propose new measures to control the outbreak.
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Joly Y, Nycum G. Currents in contemporary ethics. The tuberculosis scare in retrospect. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2007; 35:734-738. [PMID: 18076523 DOI: 10.1111/j.1748-720x.2007.00195.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Yann Joly
- HumGen International Project, Centre de recherche en droit public, at the Université de Montréal
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Schünemann HJ, Oxman AD, Fretheim A. Improving the use of research evidence in guideline development: 6. Determining which outcomes are important. Health Res Policy Syst 2006; 4:18. [PMID: 17140444 PMCID: PMC1687184 DOI: 10.1186/1478-4505-4-18] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Accepted: 12/01/2006] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the sixth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES We reviewed the literature on determining which outcomes are important for the development of guidelines. METHODS We searched five databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct a complete systematic review ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS We did not find a systematic review that addresses any of the following key questions and we found limited relevant research evidence. What methods should WHO use to identify important outcomes? Methods of outcome identification should be transparent and explicit. The consultation process should start with identification of all relevant outcomes associated with an intervention. Those affected, including consumers, should be involved in the selection of outcomes. A question driven approach (what is important?) is preferable to a data driven approach (what data are at hand?) to identify important outcomes. What type of outcomes should WHO consider and how should cultural diversity be taken account of in the selection of outcomes? Desirable (benefits, less burden and savings) and undesirable effects should be considered in all guidelines. Undesirable effects include harms (including the possibility of unanticipated adverse effects), greater burden (e.g. having to go to the doctor) and costs (including opportunity costs). Important outcomes (e.g. mortality, morbidity, quality of life) should be preferred over surrogate, indirect outcomes (e.g. cholesterol levels, lung function) that may or may not correlate with patient important outcomes. Ethical considerations should be part of the evaluation of important outcomes (e.g. impacts on autonomy). If the importance of outcomes is likely to vary across cultures, stakeholders from diverse cultures should be consulted and involved in the selection of outcomes. How should the importance of outcomes be ranked? Outcomes should be ranked by relative importance, separated into benefits and downsides. Information from research on values and preferences should inform the ranking of outcomes whenever possible. If the importance of outcomes is likely to vary across cultures, ranking of outcomes should be done in specific settings. If evidence is lacking for an important outcome, this should be acknowledged, rather than ignoring the outcome.
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Affiliation(s)
- Holger J Schünemann
- INFORMA, S.C. Epidemiologia, Istitituto Regina Elena, Via Elio Chianesi 53, 00144 Rome, Italy
| | - Andrew D Oxman
- Norwegian Knowledge Centre for the Health Services, P.O. Box 7004, St. Olavs plass, N-0130 Oslo, Norway
| | - Atle Fretheim
- Norwegian Knowledge Centre for the Health Services, P.O. Box 7004, St. Olavs plass, N-0130 Oslo, Norway
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Tobias HJ, Schafer MP, Pitesky M, Fergenson DP, Horn J, Frank M, Gard EE. Bioaerosol mass spectrometry for rapid detection of individual airborne Mycobacterium tuberculosis H37Ra particles. Appl Environ Microbiol 2005; 71:6086-95. [PMID: 16204525 PMCID: PMC1265962 DOI: 10.1128/aem.71.10.6086-6095.2005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Single-particle laser desorption/ionization time-of-flight mass spectrometry, in the form of bioaerosol mass spectrometry (BAMS), was evaluated as a rapid detector for individual airborne, micron-sized, Mycobacterium tuberculosis H37Ra particles, comprised of a single cell or a small number of clumped cells. The BAMS mass spectral signatures for aerosolized M. tuberculosis H37Ra particles were found to be distinct from M. smegmatis, Bacillus atrophaeus, and B. cereus particles, using a distinct biomarker. This is the first time a potentially unique biomarker was measured in M. tuberculosis H37Ra on a single-cell level. In addition, M. tuberculosis H37Ra and M. smegmatis were aerosolized into a bioaerosol chamber and were sampled and analyzed using BAMS, an aerodynamic particle sizer, a viable Anderson six-stage sampler, and filter cassette samplers that permitted direct counts of cells. In a background-free environment, BAMS was able to sample and detect M. tuberculosis H37Ra at airborne concentrations of >1 M. tuberculosis H37Ra-containing particles/liter of air in 20 min as determined by direct counts of filter cassette-sampled particles, and concentrations of >40 M. tuberculosis H37Ra CFU/liter of air in 1 min as determined by using viable Andersen six-stage samplers. This is a first step toward the development of a rapid, stand-alone airborne M. tuberculosis particle detector for the direct detection of M. tuberculosis bioaerosols generated by an infectious patient. Additional instrumental development is currently under way to make BAMS useful in realistic environmental and respiratory particle backgrounds expected in tuberculosis diagnostic scenarios.
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Affiliation(s)
- Herbert J Tobias
- L-452 Lawrence Livermore National Laboratory, 7000 East Ave, Livermore, CA 94550, USA
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Broyles LM, Colbert AM, Erlen JA. Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS. BIOETHICS 2005; 19:362-78. [PMID: 16222853 DOI: 10.1111/j.1467-8519.2005.00449.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Accurate self-administration of antiretroviral medication therapy for HIV/AIDS is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/AIDS as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals' medication-taking behaviour, speaks to the inherent power inequities in the patient-provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals' situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidiminsional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient-centred interventions.
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Affiliation(s)
- Lauren M Broyles
- University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA.
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