Protocol for a randomised controlled trial to evaluate the effectiveness of improving tuberculosis patients' treatment adherence via electronic monitors and an app versus usual care in Tibet

Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China

OBJECTIVES

This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China.

DESIGN

Qualitative research, semi-structured in-depth interviews.

SETTING

The TB care ecosystem in Shigatse, including primary and community care.

PARTICIPANTS

Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2).

RESULTS

The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse.

CONCLUSIONS

The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.

Effectiveness of a comprehensive package based on electronic medication monitors at improving treatment outcomes among tuberculosis patients in Tibet: a multicentre randomised controlled trial

BACKGROUND

WHO recommends that electronic medication monitors, a form of digital adherence technology, be used as a complement to directly observed treatment (DOT) for tuberculosis, as DOT is inconvenient and costly. However, existing evidence about the effectiveness of these monitors is inconclusive. Therefore, we evaluated the effectiveness of a comprehensive package based on electronic medication monitors among patients with tuberculosis in Tibet Autonomous Region (hereafter Tibet), China.

METHODS

This multicentre, randomised controlled trial recruited patients from six counties in Shigatse, Tibet. Eligible participants had drug-susceptible tuberculosis and were aged 15 years or older when starting standard tuberculosis treatment. Tuberculosis doctors recruited patients from the public tuberculosis dispensary in each county and the study statistician randomly assigned them to the intervention or control group based on the predetermined randomised allocation sequence. Intervention patients received an electronic medication monitor box. The box included audio medication-adherence reminders and recorded box-opening data, which were transmitted to a cloud-based server and were accessible to health-care providers to allow remote adherence monitoring. A linked smartphone app enabled text, audio, and video communication between patients and health-care providers. Patients were also provided with a free data plan. Patients selected a treatment supporter (often a family member) who was trained to support patients with using the electronic medication monitor and app. Patients in the control group received usual care plus a deactivated electronic medication monitor, which only recorded and transmitted box-opening data that was not made available to health-care providers. The control group also had no access to the app or trained treatment supporters. The primary outcome was a binary indicator of poor monthly adherence, defined as missing 20% or more of planned doses in the treatment month, measured using electronic medication monitor opening data, and verified by counting used medication blister packages during consultations. We recorded other secondary treatment outcomes based on national tuberculosis reporting data. We analysed the primary outcome based on the intention-to-treat population. This trial is registered at ISRCTN, 52132803.

FINDINGS

Between Nov 17, 2018, and April 5, 2021, 278 patients were enrolled into the study. 143 patients were randomly assigned to the intervention group and 135 patients to the control group. Follow-up ended when the final patient completed treatment on Oct 4, 2021. In the intervention group, 87 (10%) of the 854 treatment months showed poor adherence compared with 290 (37%) of the 795 months in the control group. The corresponding adjusted risk difference for the intervention versus control was -29·2 percentage points (95% CI -35·3 to -22·2; p<0·0001). Five of the six secondary treatment outcomes also showed clear improvements, including treatment success, which was found for 133 (94%) of the 142 individuals in the intervention arm and 98 (73%) of the 134 individuals in the control arm, with an adjusted risk difference of 21 percentage points (95% CI 12·4-29·4); p<0·0001.

INTERPRETATION

The interventions were effective at improving tuberculosis treatment adherence and outcomes, and the trial suggests that a comprehensive package involving electronic medication monitors might positively affect tuberculosis programmes in high-burden and low-resource settings.

FUNDING

TB REACH.

Challenge of ending TB in China: tuberculosis control in primary healthcare sectors under integrated TB control model-a systematic review and meta-analysis

BACKGROUND

China has the third-largest burden of tuberculosis (TB) cases in the world with great challenges towards ending TB. Primary health care (PHC) sectors play a critical role in TB prevention and control in communities under the Chinese integrated TB control model. However, there is a lack of comprehensive review of research evidence on TB control in PHC sectors under the integrated TB control model in China.

METHODS

This review was conducted following the PRISMA guidelines. Articles published from 2012 to January 2022 were searched from four international and three Chinese databases. Studies conducted inside mainland China and relevant with TB control service in PHC sectors under the integrated model were included. After study selection, data extraction, and quality assessment, the meta-analysis was performed with RevMan using a random-effect model.When I2 was more than 50%, subgroup analysis was performed to explore possible reasons for heterogeneity. We also conducted a post hoc sensitivity analysis for outcomes after meta-analysis by exclusion of studies with a high risk of bias or classified as low quality.

RESULTS

Forty-three studies from 16 provinces/municipalities in China were included in this review, and most studies included were of medium quality. PHC sectors in East China delivered TB control service better overall than that in West China, especially in tracing of patients and TB case management (TCM). In meta-analyses, both the pooled arrival rate of tracing and pooled TCM rate in East China were higher than those in West China. TB patients had a low degree of willingness to receive TCM provided by healthcare workers in PHC sectors nationwide, especially among migrant TB patients. There were 9 studies reporting factors related to TB control service in PHC sectors, 6 (2 in East and 4 in West China) of which indentified several characteristics of patients as associated factors. The context of PHC sectors was demonstrated to influence delivery of TB control service in PHC sectors in 5 studies (3 in East, 1 in Middle and 1 in West China). Most studies on strategies to promoting TB control services in PHC sectors were conducted in East China and some of these studies identified several online and offline interventions and strategies improving patients' treatment compliance [pooled OR (95% CI): 7.81 (3.08, 19.19] and awareness of TB [pooled OR (95% CI): 6.86 (2.16, 21.72)].

CONCLUSION

It is of urgent need to improve TB control in PHC sector in China, particularly in West China. Formative and implementation research with rigorous design are necessary to develop comprehensive, context-specific, and patient-centered TB control strategies to promote ending TB in China.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review

Background

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB).

Objective

This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption.

Methods

We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included.

Results

We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems.

Conclusions

This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Mobile health-based home rehabilitation education improving early outcomes after anterior cruciate ligament reconstruction: A randomized controlled clinical trial

Objective

This study aimed to assess changes in joint range of motion (ROM) and knee joint function between patients who received the mobile health-based intervention and those who received regular care at 2 and 6 weeks after anterior cruciate ligament (ACL) reconstruction to provide better interventions in the future.

Methods

Patients who underwent ACL reconstruction were randomized into the experimental [Mobile health-based intervention (MHI); n = 62] and control (CON) groups (n = 63). The CON group underwent home-based rehabilitation exercise following the paper rehabilitation schedule, while the intervention group received additional mobile health-based education at weeks 1-6 after surgery. ROM, thigh circumference difference, and flexion pain were the primary outcomes. The secondary outcomes were the international knee documentation committee knee evaluation form (IKDC) scores and rehabilitation compliance scores. All the outcomes were measured 1 day before surgery as references and at 2 and 6 weeks after surgery.

Results

There was no statistical difference in the patients' ROM, thigh circumference difference, and VAS scores at the 2-week follow-up. At the 6-week follow-up, the ROM of the affected leg was (118.1 ± 20.5)° in the CON group and (126.6 ± 20.5)° in the MHI group, and the difference was statistically significant (P = 0.011). The difference in thigh circumference was 3.0 (2.0, 3.5) cm in the CON group and 2.5 (1.0, 3.0) cm in the MHI group. The difference was statistically significant (P < 0.001). The VAS score in the CON group was 3.0 (2.0, 4.0), and the MHI group was 2.5 (1.0, 3.0). The difference was statistically significant (P < 0.05). At the 6-week follow-up, the compliance score of patients in the MHI group was significantly higher than that in the CON group (P = 0.047, β = 2.243, 95%CI: 0.026-4.459). There is no statistically significant difference in IKDC scores.

Conclusion

Mobile health-based intervention positively affected patients undergoing ACL reconstruction surgery, particularly in improving the clinical outcome indicators of the knee joint.

Effect of mobile health reminders on tuberculosis treatment outcomes in Shanghai, China: A prospective cohort study

Background

Poor adherence increases the risk of unfavorable outcomes for tuberculosis (TB) patients. Mobile health (mHealth) reminders become promising approaches to support TB patients' treatment. But their effects on TB treatment outcomes remain controversial. In this prospective cohort study, we evaluated the effect of the reminder application (app) and the smart pillbox on TB treatment outcomes compared with the standard care in Shanghai, China.

Methods

We recruited new pulmonary TB (PTB) patients diagnosed between April and November 2019 who were aged 18 or above, treated with the first-line regimen (2HREZ/4HR), and registered at Songjiang CDC (Shanghai). All eligible patients were invited to choose the standard care, the reminder app, or the smart pillbox to support their treatment. Cox proportional hazard model was fitted to assess the effect of mHealth reminders on treatment success.

Results

260 of 324 eligible patients enrolled with 88 using standard care, 82 the reminder app, and 90 the smart pillbox, followed for a total of 77,430 days. 175 (67.3%) participants were male. The median age was 32 (interquartile range [IQR] 25 to 50) years. A total of 44,785 doses were scheduled for 172 patients in the mHealth reminder groups during the study period. 44,604 (99.6%) doses were taken with 39,280 (87.7%) monitored by the mHealth reminders. A significant time-dependent downward linear trend was observed in the monthly proportion of dose intake (p < 0.001). 247 (95%) patients were successfully treated. The median treatment duration of successfully treated patients in the standard care group was 360 (IQR 283-369) days, significantly longer than those in the reminder app group (296, IQR 204-365, days) and the smart pillbox group (280, IQR 198-365, days) (both p < 0.01). Using the reminder app and the smart pillbox was associated with 1.58 times and 1.63 times increase in the possibility of treatment success compared with the standard care, respectively (both p < 0.01).

Conclusion

The reminder app and the smart pillbox interventions were acceptable and improved the treatment outcomes compared with the standard care under the programmatic setting in Shanghai, China. More high-level evidence is expected to confirm the effect of mHealth reminders on TB treatment outcomes.

Effectiveness of Mobile Medical Apps in Ensuring Medication Safety Among Patients With Chronic Diseases: Systematic Review and Meta-analysis

BACKGROUND

Along with the rapid growth of the global aging society, the mobile and health digital market has expanded greatly. Countless mobile medical apps (mmApps) have sprung up in the internet market, aiming to help patients with chronic diseases achieve medication safety.

OBJECTIVE

Based on the medication safety action plans proposed by the World Health Organization, we aimed to explore the effectiveness of mmApps in ensuring the medication safety of patients with chronic diseases, including whether mmApps can improve the willingness to report adverse drug events (ADEs), improve patients' medication adherence, and reduce medication errors. We hoped to verify our hypothesis through a systematic review and meta-analysis.

METHODS

The meta-analysis was performed in strict accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included literature searched from 7 databases-PubMed, Web Of Science, Embase, CINAHL, China National Knowledge Infrastructure, Wanfang, and SinoMed. The publication time was limited to the time of database establishment to April 30, 2022. Studies were screened based on inclusion and exclusion criteria. The data extracted included authors, years of publication, countries or regions, participants' characteristics, intervention groups, and control groups, among others. Our quality assessment followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions, Version 6.3. RevMan 5.2 software (Cochrane Collaboration) was used to analyze the statistical data, and a sensitivity analysis was performed to assess data stability. The degree of stability was calculated by using a different statistical method and excluding large-sample studies from the analysis.

RESULTS

We included 8 studies from 5 countries (China, the United States, France, Canada, and Spain) that were published from January 1, 2014, to December 31, 2021. The total number of participants was 1355, and we analyzed the characteristics of included studies, each app's features, the risk of bias, and quality. The results showed that mmApps could increase ADE reporting willingness (relative risk [RR] 2.59, 95% CI 1.26-5.30; P=.009) and significantly improve medication adherence (RR 1.17, 95% CI 1.04-1.31; P=.007), but they had little effect on reducing medication errors (RR 1.54, 95% CI 0.33-7.29; P=.58).

CONCLUSIONS

We analyzed the following three merits of mmApps, with regard to facilitating the willingness to report ADEs: mmApps facilitate more communication between patients and physicians, patients attach more importance to ADE reporting, and the processing of results is transparent. The use of mmApps improved medication adherence among patients with chronic diseases by conveying medical solutions, providing educational support, tracking medications, and allowing for remote consultations. Finally, we found 3 potential reasons for why our medication error results differed from those of other studies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022322072; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=322072.

Exploring the translation process for multilingual implementation research studies: a collaborative autoethnography

Introduction

In an increasingly globalised and interconnected world, evidence to evaluate complex interventions may be generated in multiple languages. However, despite its influence in shaping the evidence base, there is little literature explicitly connecting the translation process to the goals and processes of implementation research. This study aims to explore the processes and experience of an international implementation research team conducting a process evaluation of a complex intervention in Tibet Autonomous Region, China.

Methods

This study uses a collaborative autoethnographic approach to explore the translation process from Chinese or Tibetan to English of key stakeholder interview transcripts. In this approach, multiple researchers and translators contributed their reflections, and conducted joint analysis through dialogue, reflection and with consideration of multiple perspectives. Seven researchers involved with the translation process contributed their perspectives through in-depth interviews or written reflections and jointly analysed the resulting data.

Results

We describe the translation process, synthesise key challenges including developing a ‘voice’ and tone as a translator, conveying the depth of idioms across languages, and distance from the study context. We further offer lessons learnt including the importance of word banks with unified translations of words and phrases created iteratively during the translation process, the need to collaborate between translators and the introspective work necessary for translators to explore their positionality and reflexivity during the work. We then offer a summary of these learnings for other implementation research teams.

Conclusion

Our findings emphasise that in order to ensure rigour in their work, implementation research teams using qualitative data should make concerted effort to consider both the translation process as well as its outcomes. Given the numerous multinational or multilingual implementation research studies using qualitative methods, there is a need for further consideration and reflection on the translation process.

Evaluation of Mobile Application for the Management of Tuberculosis Patients in Tianjin During 2019-2020

PURPOSE

Poor tuberculosis (TB) medication adherence increases the risk of treatment failure and development of drug-resistant TB, while universal implementation of directly observed therapy (DOT) is not feasible in China. EHealth technologies were reported to be promising patient-centered tools for improving adherence. However, only pilot studies have assessed patients' experiences, and the results were discrepant.

PATIENTS AND METHODS

This prospective-cohort study was conducted among TB patients at the outpatient department from 3 March 2019 to 30 May 2020 in Tianjin, China. Data were downloaded from the Tuberculosis Doctor App and TB Information Management System (TBIMS) and merged them by the TBIMS notification number. Logistic regression analysis was used to analyze the factors associated with regular drug-intake. Odds ratios and 95% confidence intervals were estimated with and without adjustment for age, gender, ethnicity and occupation.

RESULTS

Revisit examination was more regularly and frequently in APP group than non-APP group. In APP group, 33.28% patients were regular drug-intake. The whole drug-intake rate was 84.84%. Tuberculosis pleurisy (aOR: 0.42, 95CI%=0.26-0.69) and retreated patients (aOR: 0.40, 95CI% =0.27-0.59) were more likely to have poor medication compliance. Local residents tend to have better medication compliance (aOR: 1.80, 95CI% =1.16-2.79).

CONCLUSION

APP could improve TB patients' revisit examination adherence. Medication adherence was poor in tuberculosis pleuritis and retreated patients, while local residents tend to have better medication adherence. To make full use of the mobile application in TB patient management, more incentive measures should be adopted for patients and doctors, respectively.

A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China

Background

Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB.

Methods

We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al.

Results

Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment.

Conclusions

We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00906-4.

Adherence to Multidrug Resistant Tuberculosis Treatment and Case Management in Chongqing, China - A Mixed Method Research Study

Aim

This paper evaluated the treatment adherence for multidrug-resistant tuberculosis (MDR-TB) and MDR-TB case management (MTCM) in Chongqing, China in order to identify factors associated with poor treatment adherence and case management.

Methods

Surveys with 132 MDR-TB patients and six in-depth interviews with health care workers (HCWs) from primary health centers (PHC), doctors from MDR-TB designated hospitals and MDR-TB patients were conducted. Surveys collected demographic and socio-economic characteristics, as well as factors associated with treatment and case management. In-depth interviews gathered information on treatment and case management experience and adherence behaviors.

Results

Patient surveys found the two main reasons for poor adherence were negative side-effects from the treatment and busy work schedules. In-depth interviews with key stakeholders found that self-perceived symptom improvement, negative side-effects from treatment and financial difficulties were the main reasons for poor adherence. MDR-TB patients from urban areas, who were unmarried, were female, had migrant status, and whose treatments were supervised by health care workers from primary health clinics, had poorer treatment adherence (P<0.05). Among the MDR-TB patients surveyed, 86.7% received any type of MTCM in general (received any kind of MTCM from HCWs in PHC, MDR-TB designated hospital and centers of disease control/TB dispensaries and 62.50% received MTCM from HCWs in PHC sectors). Patients from suburban areas were more likely to receive both MTCM in general (OR=6.70) and MTCM from HCWs in MDR-TB designated hospitals (OR=2.77), but female patients (OR=0.26) were less likely to receive MTCM from HCWs in PHC sectors, and patients who were not educated about MTCM by TB doctors in designated hospitals were less likely to receive MTCM in general (OR=0.14). Patients who had not been hospitalized were less likely to receive MTCM from HCWs in MDR-TB designated hospitals (OR=0.21).

Conclusion

Stronger MTCM by HCWs in PHC sectors would improve treatment adherence among MDR-TB patients. Community-based patient-centered models of MTCM in PHC sectors and the use of digital health technology could help to improve case management and thereby improve adherence.

An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial

BACKGROUND

Inappropriate prescribing of antibiotics for acute respiratory infections at the primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China's primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages.

METHODS

We will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: (1) training using new operational guidelines, (2) improved management and peer-review of antibiotic prescribing, (3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months' post-trial long-term follow-up.

DISCUSSION

Our study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All interventional activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN96892547. Registered on 18 August 2019.

Factors Influencing Medication Nonadherence to Pulmonary Tuberculosis Treatment in Tibet, China: A Qualitative Study from the Patient Perspective

PURPOSE

Medication nonadherence is one of the most significant obstacles to tuberculosis (TB) control worldwide. Identification of the factors associated with medication nonadherence is important. However, few related studies have been carried out in Tibet. This study aimed to explore factors influencing medication nonadherence to pulmonary TB (PTB) treatment in Tibet, China, from the patient perspective.

PATIENTS AND METHODS

In this qualitative study, seventeen PTB patients in Tibet were recruited by purposive and maximum variation sampling methods. In-depth semistructured interviews were conducted to collect data on factors influencing medication nonadherence, and Colaizzi's seven-step method was used to analyze the data.

RESULTS

The medication nonadherence of PTB patients in Tibet was influenced by one or a combination of the following four factors. First, patient-related factors included a lack of knowledge of PTB treatment, poor self-management capability, poor self-regulation capability and misperception of health condition. Second, a medication-related factor was medication side effects. Third, health service-related factors included the poor treatment skills of doctors in primary hospitals and a lack of directly observed treatment (DOT). Last, sociocultural factors included the effect of traditional Tibetan medicine, lack of family member support and discrimination.

CONCLUSION

Multiple interplaying factors influenced medication nonadherence during PTB treatment in Tibet, and the main influencing factors were a lack of knowledge about PTB treatment, poor self-management capability, and the effect of traditional Tibetan medicine. TB health workers in Tibet should provide permanently viewable PTB treatment knowledge materials to PTB patients when oral health education is conducted, find feasible alternative strategies to DOT and establish links to traditional Tibetan medicine hospitals.