Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment

The active search for respiratory symptomatics for the control of tuberculosis in the Potiguara Indigenous Scenario, Paraiba, Brazil

This study sought to analyze the actions of an active search for respiratory symptomatics (RSs) in the control of tuberculosis (TB) in the Potiguara Special Indigenous Sanitary District, Paraiba, Brazil, between May and June 2007. After approval by the Research Ethics Committee, 23 professionals were grouped, including physicians, nurses, nurse technicians and indigenous health agents. The focus group technique was used as an instrument for data collection, based on the discourse analysis technique. Weaknesses of an operational nature that became apparent, related to the organization of local health service for the implementation of routines for diagnosing TB: absence of a systematic routine for searching for RSs, difficulties in organizing the material for bacteriological examination, inadequate approach to patient during sputum collection and inadequate professional training. It is deemed necessary to improve the organization of services for early detection of TB cases in the local indigenous scenario.

Tuberculosis knowledge, attitudes, and beliefs in foreign-born and US-born patients with latent tuberculosis infection

Foreign-born individuals comprise the majority of patients treated for latent tuberculosis infection (LTBI) in the US. It is important to understand this population's tuberculosis-related knowledge, attitudes, and beliefs (KAB) as they may affect treatment acceptance and completion. KAB in 84 US-born and 167 foreign-born LTBI patients enrolled in a clinical trial assessing treatment completion at an urban public hospital were assessed at baseline. Demographic and substance use information was also collected.

RESULTS

Of 251 participants, 66.5% were foreign-born. While misconceptions existed among both US and foreign-born regarding transmission and contagiousness of LTBI, overall knowledge scores did not differ significantly between groups. With respect to attitudinal factors, foreign-born participants were less likely to acknowledge that they had LTBI and felt more "protected" from developing TB. Improved understanding of foreign-born patients' KAB may contribute to the reduction of barriers to treatment and improved outcomes.

Urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of Pakistan's Punjab province

Objective

The aim of this study was to explore inequities in knowledge, attitudes and practices regarding tuberculosis (TB) among the urban and rural populations.

Design

A cross-sectional study was conducted in two districts of Pakistan's Punjab province. The 1080 subjects aged 20 years and above, including 432 urban and 648 rural respondents, were randomly selected using multistage cluster sampling and interviewed after taking verbal informed consent. Logistic regression was used to calculate the crude odds ratio (OR) with 95% confidence interval (CI) for the urban area. The differences in knowledge, attitudes, practices and information sources between the urban and rural respondents were highlighted using Pearson chi-square test and Fisher's exact test.

Results

The study revealed poor knowledge regarding TB. The deficit was greater in the rural areas in all aspects. The knowledge regarding symptoms (OR 2.03, 95% CI 1.59-2.61), transmission (OR 1.93, 95% CI 1.44-2.59), prevention (OR 2.24, 95% CI 1.70-2.96), duration of standard treatment (OR 1.88, 95% 1.41-2.49) and DOTS (OR 1.84, 95% CI 1.43-2.38) was significantly higher in the urban areas (all P < 0.001). Although a majority of the subjects (urban 83.8%, rural 81.2%) were aware of the correct treatment for TB, less than half (urban 48.1%, rural 49.2%) were aware of the availability of the diagnostic facility and treatment free of cost. The practice of seeking treatment at a health facility (P = 0.030; OR 2.01, 95% CI 1.06-3.82), as soon as they realized that they had TB symptoms (P < 0.001; OR 1.72, 95% CI 1.26-2.35), was significantly higher in the urban areas. People in the urban areas were more likely to feel ashamed and embarrassed being a TB patient (P < 0.001; OR 2.03, 95% CI 1.50-2.76); however, they seem to be supportive in case their family member suffered from TB (P = 0.005; OR 1.53, 95% CI 1.13-2.06). Nearly half of the respondents, irrespective of the area of residence, believed that the community rejects the TB patient (urban 49.8%, rural 46.4%). Television (urban 80.1%, rural 68.1%) and health workers (urban 30.6%, rural 41.4%) were the main sources for people to acquire the TB related information.

Conclusion

Respondents' knowledge regarding TB was deficient in all aspects, particularly in the rural areas. Intended health seeking behavior was better in the urban areas. Television and health workers were the main sources for TB related information in both the urban as well as the rural areas. Therefore, the area of residence should be considered in tailoring communication strategies and designing future interventions for TB prevention and control.

Illness costs to households are a key barrier to access diagnostic and treatment services for tuberculosis in Tajikistan

BACKGROUND

Tuberculosis (TB) control is based on early detection and complete treatment of infectious cases. Consequently, it is important that TB suspects and patients can readily access medical care. This qualitative study investigated determinants of access to DOTS services as identified by patients, health providers and community members in four districts in Tajikistan.

FINDINGS

Focus group discussions were conducted in order to investigate access to TB services. A conceptual framework for access to care guided the analysis. Thirteen focus group discussions involving a total of 97 informants were conducted. Content analysis of discussions and a rating to quantify the relative importance of discussed factors were carried out. The conceptual framework identifies five main components of access to which factors can be assigned: availability, adequacy, acceptability, accessibility and affordability.Financial factors were considered the most important determinants of access to diagnosis and treatment of tuberculosis. Expenditure for drugs and consultations, for transport, and for special foods as well as lost income were identified as major barriers to treatment. Stigma, doubts about curability and low perceived quality of care were not seen to be significant determinants of access to care for tuberculosis. Community members were well aware of symptoms of tuberculosis and of medical services. These findings were consistent between different respondent groups (community members, patients and providers). They were also highly consistent between the open discussion and the confidential rating.

CONCLUSIONS

Illness-costs to households were identified as the main barrier to tuberculosis diagnosis and treatment. To improve access and ultimately adherence to tuberculosis treatment, effective mitigation strategies, e.g. changes in case management, food contributions or financial stimuli, need to be explored and implemented.

Intensive phase non-compliance to anti tubercular treatment in patients with HIV-TB coinfection: a hospital-based cross-sectional study

We aimed to study the prevalence and determinants of non compliance to intensive phase anti tubercular treatment (ATT) in 111 HIV-TB coinfection patients, attending the APEX Referral Center for HIV/AIDS at Medical College, Kolkata with a specially-designed, semi-structured, pre-tested questionnaire. Compliance was defined as taking ≥95% of the total scheduled doses of anti-TB medicines during the intensive phase. Data was collected on socio-demographic parameters, disease information, patient's knowledge and barriers to treatment. The prevalence of non-compliance to ATT in HIV-TB coinfection patients was found to be 40.5% (95% C.I. = 30.5, 50.5). Multivariate logistic regression analysis showed that absence of proper counseling, lack of knowledge about correct route of TB transmission, visiting quacks during ATT and the urge to leave treatment once patient started feeling better were the significant determinants of non-compliance. "No Counseling" increased chances of non- compliance (adjusted O.R.) 47.12 times (95% C.I. = 7.99, 195.27); thereby being the single most influential variable towards the outcome. The present study finds an alarmingly high prevalence of non-compliance to ATT among HIV-TB coinfection patients. The results clearly indicate that adequate counseling about this coinfection and the importance of compliance, along with better patient-friendly orientation of DOTS programme is urgently needed. Collaborative TB-HIV activities are essential to ensure better ATT compliance in coinfection patients.

A qualitative review: the stigma of tuberculosis

BACKGROUND

Tuberculosis is a major health problem internationally and brings with it a range of physical, economic and social consequences. There is a stigma associated with having tuberculosis because the disease is commonly viewed as a 'dirty disease'. This stigma can have a negative impact on an individual and may delay the person seeking treatment.

AIMS

The aim of this review was to explore the stigma and impact of having tuberculosis or having a family member with tuberculosis.

DESIGN

Literature review.

METHOD

A comprehensive search of the electronic databases was undertaken. Inclusion criteria for the review were studies that investigated people with tuberculosis or their families, focused on the stigma or impact of tuberculosis and reported descriptions of the experience. Data were synthesised using a thematic analysis.

RESULTS

The literature search identified thirty studies. Three themes emerged from the synthesis: shame, isolation and fear. The shame related to tuberculosis being viewed as a bad disease, a dirty disease. Isolation involved both the withdrawal from social contact and the shunning of contact by other people. Fear was a consequence of the many difficulties that accompany tuberculosis. These factors operated at three levels, on the individual level, the family level and the societal level.

CONCLUSION

The stigma that accompanies tuberculosis can have a negative impact on the individual and family and may result in their withdrawal from society because of shame and fear. The review highlights the need for education to provide practical strategies for individuals and families and to educate communities where tuberculosis is endemic. Relevance to clinical practice.  The review highlights the widespread ignorance of tuberculosis and need for education of the individual, family and community. This education should provide practical strategies to help people cope with tuberculosis. It also suggests that ensuring confidentiality should be an important component of management strategies.

Effects of pay-for-performance system on tuberculosis default cases control and treatment in Taiwan

Objectives

In order to make tuberculosis (TB) treatment more effective and to lower the default rate of the disease, the Bureau of National Health Insurance (BNHI) in Taiwan implemented the “pay-for-performance on Tuberculosis” program (P4P on TB) in 2004. The purpose of this study is to investigate the effectiveness of the P4P system in terms of default rate.

Methods

This is a retrospective study. National Health Insurance Research Datasets in Taiwan from 2002 to 2005 has been used for the study. The study compared the differences of TB default rate before and after the implementation of P4P program, between participating and non-participating hospitals, and between P4P hospitals with and without case managers. Furthermore, logistic regression analysis was conducted to explore the related factors influencing TB patients default treatment after TB detected.

Results

The treatment default rate after “P4P on TB” was 11.37% compared with the 15.56% before “P4P on TB” implementation. The treatment default rate in P4P hospitals was 10.67% compared to 12.7% in non-P4P hospitals. In addition, the default rate was 10.4% in hospitals with case managers compared with 12.68% in hospitals without case managers.

Conclusions

The results of the study showed that “P4P on TB” program improved the treatment default rate for TB patients. In addition, case managers improved the treatment outcome in controlling patients’ default rate.

The experience of college students with pulmonary tuberculosis in Shaanxi, China: a qualitative study

Background

The prevalence of pulmonary tuberculosis among college students in Shaanxi is high. Although tuberculosis leaves much psychological and social impact on patients, little is known about its impact on college students. The objective of this study is to explore the experiences and psychological process of college students with pulmonary tuberculosis in Shaanxi, China.

Methods

17 college students with pulmonary tuberculosis were recruited purposively from 9 colleges in Shaanxi. In-depth interviews were conducted to collect data and a thematic framework analysis was used.

Results

The participants reported that pulmonary tuberculosis deeply influenced their mental health. They were fearful to the nature of pulmonary tuberculosis at the stage of diagnosis, anxious about the illness before the period of diagnosis and the early week of the treatment, excessive worry immediately before the first recheck. They expected an early full recovery, bored on tedious treatment life and worried about future heath and prospects during the whole treatment phase. Their daily life was also influenced, namely discontinued studies, isolation and increased financial burden. They also reported that they could get strong supports from family members, while little supports from healthcare workers and their friends.

Conclusions

The participants' psychological pressure was significant during the treatment. In addition, there was serious conflict between treatment and study; social support provided for them was insufficient. Healthcare workers should provide psychological support for college students with pulmonary tuberculosis according to the psychological characteristics and offer social support through strengthening communication with them. Colleges should follow governmental policies on TB exactly and provide opportunities for the patients to continue their studies.

Social stigma and knowledge of tuberculosis and HIV among patients with both diseases in Thailand

INTRODUCTION

Disease-related stigma and knowledge are believed to be associated with patients' willingness to seek treatment and adherence to treatment. HIV-associated tuberculosis (TB) presents unique challenges, because TB and HIV are both medically complex and stigmatizing diseases. In Thailand, we assessed knowledge and beliefs about these diseases among HIV-infected TB patients.

METHODS

We prospectively interviewed and examined HIV-infected TB patients from three provinces and one national referral hospital in Thailand from 2005-2006. At the beginning of TB treatment, we asked patients standardized questions about TB stigma, TB knowledge, and HIV knowledge. Responses were grouped into scores; scores equal to or greater than the median score of study population were considered high. Multiple logistic regression analysis was used to identify factors associated with scores.

RESULTS

Of 769 patients enrolled, 500 (65%) reported high TB stigma, 177 (23%) low TB knowledge, and 379 (49%) low HIV knowledge. Patients reporting high TB stigma were more likely to have taken antibiotics before TB treatment, to have first visited a traditional healer or private provider, to not know that monogamy can reduce the risk of acquiring HIV infection, and to have been hospitalized at enrollment. Patients with low TB knowledge were more likely to have severe TB disease, to be hospitalized at enrollment, to be treated at the national infectious diseases referral hospital, and to have low HIV knowledge. Patients with low HIV knowledge were more likely to know a TB patient and to have low TB knowledge.

DISCUSSION

We found that stigma and low disease-specific knowledge were common among HIV-infected TB patients and associated with similar factors. Further research is needed to determine whether reducing stigma and increasing TB and HIV knowledge among the general community and patients reduces diagnostic delay and improves patient outcomes.

A study of the impact of tuberculosis on the quality of life and the effect after treatment with DOTS

A prospective study was conducted on 90 patients of tuberculosis at 2 directly observed treatment short course (DOTS) cum microscopy centers in an urban area of Delhi. The WHOQOL-BREF (Hindi) questionnaire was used to assess the QOL at the onset of treatment, after 3 months of treatment under DOTS, and at completion of treatment. Patients with tuberculosis had significantly lower mean scores than controls for overall QOL. The most affected domains were physical and psychological. Women scored significantly better than men in the physical and environmental domains. Overall QOL scores were lowest for category II and significantly lower for the psychological and social domains. The mean scores after treatment were significantly lower than controls for overall QOL, the social and environmental domains. The DOTS regimen improves the QOL and its domains; however, they remain significantly affected compared to the healthy controls.

Perception and management of tuberculosis symptoms in Addis Ababa, Ethiopia

Management of early tuberculosis (TB) symptoms and adherence to medical treatment are main challenges in controlling TB. The aim of this study is to explore how symptoms of TB are perceived and managed, from the onset of symptoms and during the course of treatment, in Addis Ababa, Ethiopia. We conducted a qualitative interview study, including 50 in-depth interviews and 2 focus groups, with TB patients, their relatives, and health personnel. We found that a patient's perceptions and self-treatment of early symptoms could cause diagnostic delay. Stigma associated with TB and public health services made many patients approach private clinics, causing further delay. Both private and public clinics often labeled and managed symptoms according to lay explanatory models. Lack of adequate knowledge about TB's etiology and cure caused patients to continue relating to symptoms by reference to their own understanding. This affected patients' ability to manage TB and its treatment.

Tackling tuberculosis patients' internalized social stigma through patient centred care: an intervention study in rural Nicaragua

Background

We report a patient-centered intervention study in 9 municipalities of rural Nicaragua aiming at a reduction of internalized social stigma in new AFB positive tuberculosis (TB) patients diagnosed between March 2004 and July 2005.

Methods

Five out of 9 municipal teams were coached to tailor and introduce patient-centered package. New TB patients were assigned to the intervention group when diagnosed in municipalities implementing effectively at least TB clubs and home visits.

We compared the changes in internalized stigma and TB treatment outcome in intervention and control groups. The internalized stigma was measured through score computed at 15 days and at 2 months of treatment. The treatment results were evaluated through classical TB program indicators. In all municipalities, we emphasized process monitoring to capture contextual factors that could influence package implementation, including stakeholders.

Results

TB clubs and home visits were effectively implemented in 2 municipalities after June 2004 and in 3 municipalities after January 2005. Therefore, 122 patients were included in the intervention group and 146 in the control group. After 15 days, internalized stigma scores were equivalent in both groups. After 2 months, difference between scores was statistically significant, revealing a decreased internalized stigma in the intervention group and not in the control group.

Conclusion

This study provides initial evidences that it is possible to act on TB patients' internalized stigma, in contexts where at least patient centered home visits and TB clubs are successfully implemented. This is important as, indeed, TB care should also focus on the TB patient's wellbeing and not solely on TB epidemics control.

Measuring stigma associated with tuberculosis and HIV/AIDS in southern Thailand: exploratory and confirmatory factor analyses of two new scales

OBJECTIVE

To develop scales to measure tuberculosis and HIV/AIDS stigma in a developing world context.

METHODS

Cross-sectional study of tuberculosis patients in southern Thailand, who were asked to rate their agreement with items measuring TB and HIV/AIDS stigma. Developing the scales involved exploratory and confirmatory factor analyses, internal consistency, construct validity, test-retest reliability and standardized summary scores.

RESULTS

Factor analyses identified two sub-scales associated with both tuberculosis and HIV/AIDS stigma: community and patient perspectives. Goodness-of-fit was good (TLI = 94, LFI = 0.88 and RMSEA = 0.11), internal consistency was excellent (Cronbach's alphas 0.82-0.91), test-retest reliability was moderate, and construct validity showed an inverse correlation with social support.

CONCLUSION

Our scales have good psychometric properties that measure stigma associated with tuberculosis and HIV/AIDS and allow assessment of stigma from community and patient perspectives. Their use will help document the burden of stigma, guide the development of interventions and evaluate stigma reduction programmes in areas with a high HIV/AIDS and tuberculosis burden.

Treatment default among urban tuberculosis patients, Thailand

Tuberculosis treatment default, missing medical appointments for two consecutive months or more, is a serious problem not only for individuals but also for societies and health-care systems. Most research focuses only on patient factors without considering health-care system factors' effects on treatment default. The study purpose was to examine the influence of process of care on treatment default. Structured interviews and medical chart reviews were conducted in 160 tuberculosis patients receiving care at a tertiary hospital in Thailand. The samples included 54 patients with treatment default and 106 patients with treatment completion. Hierarchical logistic regression was used to examine relationships among the variables. After adjusting for patient factors, having severe medication side-effect and travel time to clinic increased treatment default. The patient factor of being paid on a daily basis was also significantly associated with treatment default. Evidence indicates that some process of care factors influence treatment default. Findings can be applied to practice levels to maintain patients until treatment completion.

Barriers and enablers in the management of tuberculosis treatment in Addis Ababa, Ethiopia: a qualitative study

Background

Non-adherence to tuberculosis (TB) treatment is an important barrier for TB control programs because incomplete treatment may result in prolonged infectiousness, drug resistance, relapse, and death. The aim of the present study is to explore enablers and barriers in the management of TB treatment during the first five months of treatment in Addis Ababa, Ethiopia.

Methods

Qualitative study which included 50 in-depth interviews and two focus groups with TB patients, their relatives and health personnel.

Results

We found that loss of employment or the possibility to work led to a chain of interrelated barriers for most TB patients. Daily treatment was time-consuming and physically demanding, and rigid routines at health clinics reinforced many of the emerging problems. Patients with limited access to financial or practical help from relatives or friends experienced that the total costs of attending treatment exceeded their available resources. This was a barrier to adherence already during early stages of treatment. A large group of patients still managed to continue treatment, mainly because relatives or community members provided food, encouragement and sometimes money for transport. Lack of income over time, combined with daily accumulating costs and other struggles, made patients vulnerable to interruption during later stages of treatment. Patients who were poor due to illness or slow progression, and who did not manage to restore their health and social status, were particularly vulnerable to non-adherence. Such patients lost access to essential financial and practical support over time, often because relatives and friends were financially and socially exhausted by supporting them.

Conclusion

Patients' ability to manage TB treatment is a product of dynamic processes, in which social and economic costs and other burdens change and interplay over time. Interventions to facilitate adherence to TB treatment needs to address both time-specific and local factors.

The contribution of volunteers to a successful community-orientated tuberculosis treatment centre in an urban setting in Nepal: a qualitative assessment of volunteers' roles and motivations

PURPOSE

The purpose of the paper is to show that community involvement is a successful way of overcoming certain barriers to the successful management of the current tuberculosis epidemic, namely delayed presentation and non-completion of treatment. Volunteers are an important resource for engaging with the community. This research, conducted in an urban TB treatment centre in Nepal, seeks to investigate the motivations of TB volunteers, and how these motivations can be increased to involve volunteers, and the community, in fulfilling their maximum potential in delivering successful TB treatment programmes.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews were carried out with 26 TB volunteers, followed by volunteer discussion groups. Topics covered included: detailed accounts of the volunteers' many and varied roles; motivations - how they initially became involved and why they continue to be involved; incentives for volunteering; problems they have encountered; family and friends' attitudes to their volunteering, and the future of TB volunteering.

FINDINGS

The findings show that the TB volunteers are involved in many important roles. Volunteers initially became involved, having been asked or informed about the programme by area committee members, staff or friends. Most were also involved in other voluntary work.

ORIGINALITY/VALUE

This paper gives recommendations for volunteer programmes in developing countries including: sustained communication and contact between volunteers and the organisation; volunteer programmes based in a centre with an established community focus; flexibility of time commitment; regular recruitment drives for volunteers from different generations and status levels; and the use of training as a possible incentive for volunteering.

[Profile of notified tuberculosis cases and factors associated with treatment dropout]

OBJECTIVE

To describe the profile of notified tuberculosis cases and analyze the factors associated with treatment dropout.

METHODS

A total of 178 cases of tuberculosis notified in the western region of Belo Horizonte (Southeastern Brazil) in 2001 and 2002 and recorded in the National System for Notifiable Diseases were described. An unmatched case-control study was conducted, with data collected by means of interviews, to compare patients who dropped out of treatment with those who achieved cure. The following variables were analyzed: sociodemographic and behavioral characteristics, associations with AIDS, side effects, information on the disease and interest in treatment. Univariate analysis and unconditional logistic regression for multivariate analysis were used. Adjusted odds ratios with 95% confidence limits were used as the measurement for associations.

RESULTS

The coefficient of incidence was 56.6/100,000 inhabitants. There was predominance of men aged 30 to 49 years and of the pulmonary form (76.4%) and bacillary form (72.5%). Among the notified cases, 65.2% achieved cure, 12.4% dropped out of treatment and 9.6% died. Treatment location had no influence on the results. In the case-control study, there was no difference regarding gender, color, schooling, income, occupation, family support, association with AIDS and alcohol consumption. The use of drugs, interest in treatment and information about the disease were shown to be independently associated with dropout.

CONCLUSIONS

Adherence to treatment is a challenge in controlling tuberculosis. The protection factors (interest in treatment and information about the disease) and recognition that drug use is a risk factor must form part of the strategies for patient care in order to reduce dropout rates and restore health.

[Hospitalizations for pulmonary tuberculosis in the State of São Paulo in 2004]

Tuberculosis (TB) continues as one of the main challenges for public health and primary health care.

OBJECTIVE

To analyze hospitalizations for pulmonary TB that occurred in the State of São Paulo in 2004.

METHODOLOGY

Data were collected related to: number of hospitalizations for pulmonary tuberculosis according to gender and age range; average hospitalization time; deaths during hospitalizations and hospitalization costs for the Unified Health System (SUS), using DATASUS, the SUS database.

RESULTS

In 2004, 4,859 hospitalizations for pulmonary tuberculosis occurred in the State of São Paulo. Hospitalizations were more frequent among men, with 4079 (84%) cases; average hospitalization time was 26.2 days; 202 (4.53%) patients died, 155 of whom were men; higher costs were found for patients under 14.

CONCLUSION

Early diagnosis is essential in the identification of TB, with a view to reducing the number of TB hospitalizations, however there is a need for a primary health care service that is capable of accomplishing these actions.

Delay in seeking treatment and adherence to tuberculosis medications in Russia: a survey of patients from two clinics

BACKGROUND

Tuberculosis is a global problem, especially in high burden countries such as Russia, that is fueled by delay in seeking treatment and nonadherence to prescribed medications. Stigma and illness representation (a person's mental image of a specific illness) have the potential to affect treatment seeking and adherence.

OBJECTIVES

To describe the illness representation of tuberculosis in Russians with active pulmonary tuberculosis, and to determine if stigma and illness representation are predictors of delay in seeking treatment and adherence to tuberculosis medications.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Two outpatient clinics in the Vladimir Region, Russia.

PARTICIPANTS

A total of 105 adults, 18 years and older, being treated for active pulmonary tuberculosis, and on outpatient therapy for a minimum of four weeks participated in this study.

METHODS

Delay was measured with a question asking length of time between onset of symptoms and appointment with a physician. Stigma was measured using the Social Impact Scale. Illness representation was measured using the Revised Illness Perception Questionnaire. Participants' outpatient medication records were reviewed for medication adherence.

RESULTS

Symptoms reported were not consistent with those described in the medical literature and other studies. Only four subjects suspected tuberculosis based on their symptoms; 60% believed they had other respiratory infections. Multiple regression showed that illness identity (an attribute of illness representation) (beta=0.23) was a significant predictor of delay, accounting for 29% of the variance (p=0.008); and financial insecurity (beta=-0.28) and internalized shame (beta=0.27) (measures of stigma) were both significant predictors of medication adherence, accounting for 23% of the variance (p=0.003).

CONCLUSIONS

Illness identity was associated with delay. Internalized shame was associated with increased medication adherence while financial insecurity was associated with decreased adherence. Results point to the need for broad, culturally specific patient, family, and community education programs.

Causes of stigma and discrimination associated with tuberculosis in Nepal: a qualitative study

BACKGROUND

Tuberculosis (TB) is a major cause of death. The condition is highly stigmatised, with considerable discrimination towards sufferers. Although there have been several studies assessing the extent of such discrimination, there is little published research explicitly investigating the causes of the stigma and discrimination associated with TB. The objectives of our research were therefore to take the first steps towards determining the causes of discrimination associated with TB.

METHODS

Data collection was performed in Kathmandu, Nepal. Thirty four in-depth interviews were performed with TB patients, family members of patients, and members of the community.

RESULTS

Causes of self-discrimination identified included fear of transmitting TB, and avoiding gossip and potential discrimination. Causes of discrimination by members of the general public included: fear of a perceived risk of infection; perceived links between TB and other causes of discrimination, particularly poverty and low caste; perceived links between TB and disreputable behaviour; and perceptions that TB was a divine punishment. Furthermore, some patients felt they were discriminated against by health workers

CONCLUSION

A comprehensive package of interventions, tailored to the local context, will be needed to address the multiple causes of discrimination identified: basic population-wide health education is unlikely to be effective.

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.

Costs of a successful public-private partnership for TB control in an urban setting in Nepal

Background

In South Asia a large number of patients seek treatment for TB from private practitioners (PPs), and there is increasing international interest in involving PPs in TB control. To evaluate the feasibility, effectiveness and costs of public-private partnerships (PPPs) for TB control, a PPP was developed in Lalitpur municipality, Nepal, where it is estimated that 50% of patients with TB are managed in the private sector. From the clinical perspective the PPP was shown to be effective. The aim of this paper is to assess and report on the costs involved in the PPP scheme.

Methods

The approach to costing took a comprehensive view, with inclusion of costs not only incurred by health facilities but also social costs borne by patients and their escorts. Semi-structured questionnaires and guided interviews were used to collect start-up and recurrent costs for the scheme.

Results

Overall costs for treating a TB patient under the PPP scheme averaged US$89.60. Start-up costs per patient represented 12% of the total budget. Half of recurrent costs were incurred by patients and their escorts, with institutional costs representing most of the rest. Female patients tended to spend more and patients referred from the private sector had the highest reported costs.

Conclusion

Treating TB patients in the PPP scheme had a low additional cost, while doubling the case notification rate and maintaining a high success rate. Costs incurred by patients and their escorts were the largest contributors to the overall total. This suggests a focus for follow-up studies and for cost-minimisation strategies.

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.

Implementing WHO DOTS strategy in the Russian Federation: stakeholder attitudes

Russia has the ninth highest tuberculosis burden in the world. After a period of decline starting in the 1960s, the case notification rate tripled during the 1990s. Historically, case-finding, treatment and reporting practices in Russia have differed from those advocated by WHO and the international community: Directly Observed Therapy--short course (DOTS). By 2003, approximately 26% of the population in Russia was covered by the DOTS strategy. By contrast, the average coverage in the 22 high-burden countries is 61%. The reasons for this low rate in Russia have not been systematically examined. Using qualitative research methods we explored, in depth, the attitudes of key stakeholders involved in tuberculosis control to introduction of DOTS in a region of Russia. Six focus groups and 128 in depth interviews were held with clinicians, managers, policy-makers and patients. The results show negative attitude to change due to inadequate understanding of DOTS; perceived 'directiveness' of the 'externally developed' DOTS strategy and the standardized nature of the treatment regimen. The doctors, managers and patients saw that prolonged periods of hospitalisation (the traditional way of managing TB in Russia) was advantageous because treatment routines could be ensured, medical expertise was readily available, and other needs such as shelter and food were provided. Respondents felt that the patients were unlikely to adhere to treatment in the community. Cultural issues and capacity constraints, especially in laboratory equipment and personnel, would impede introduction and sustainability of the DOTS strategy.

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.

Clinic staff perceptions of tuberculosis treatment delivery in Bali

A number of studies have investigated patient perceptions of tuberculosis (TB) treatment delivery, but few have systematically investigated the perceptions of clinic staff. We therefore conducted individual interviews using Q-methodology with 25 staff directly involved in the delivery of TB treatment services in 18 different public sector health centres in Bali. Factor analysis was used to identify shared perceptions of TB treatment delivery in Bali among the sample studied. Three distinct perspectives emerged, indicating that all staff do not have shared understandings of difficulties and priorities in TB treatment. The main areas of difference in staff perceptions concerned the existence of barriers to treatment and the focus on the community context of TB treatment. The demonstrated variation in the perceptions of TB treatment delivery in Bali has important implications for the design of strategies to improve treatment delivery and the control of TB.

Quality of life in tuberculosis: a review of the English language literature

INTRODUCTION

Tuberculosis (TB) studies have concentrated on clinical outcomes; few studies have examined the impact of TB on patients' quality of life (QOL).

METHODS

A systematic review of published medical literature using specific MESH terms: [Tuberculosis] and 1-[Outcome], 2-[Outcome Assessment], 3-[Quality of Life], 4-[Mood Disorder], 5-[Cost and Cost Analysis], 6-[Religion], 7-[Perception], 8-[Social Support], 9-[Optimism], 10-[Stress], 11-[Signs and Symptoms], and 12-[Cost of Illness]. This yielded 1972 articles; 60 articles met inclusion criteria and were reviewed.

RESULTS

TB somatic symptoms have been well studied, but there were no studies of effects on physical functioning or general health perceptions. Patients tend to be worried, frustrated, or disappointed by their diagnosis, but it is unknown how emotional health changes with treatment. Diagnosed patients are less likely to find work, and less able to work and care for their families. TB creates the greatest financial burden on the poor. In developing, countries, patients and their families are ostracized by society, and families sometimes ostracize patients; the extent of TB's social stigma in the developed countries is unknown.

CONCLUSION

There has been relatively little research on TB QOL and even less in developed countries. A better understanding may help improve treatment regimens, adherence to treatment, and functioning and well-being of people with TB.

Factors influencing quality of life in patients with active tuberculosis

BACKGROUND

With effective treatment strategies, the focus of tuberculosis (TB) management has shifted from the prevention of mortality to the avoidance of morbidity. As such, there should be an increased focus on quality of life (QoL) experienced by individuals being treated for TB. The objective of our study was to identify areas of QoL that are affected by active TB using focus groups and individual interviews.

METHODS

English, Cantonese, and Punjabi-speaking subjects with active TB who were receiving treatment were eligible for recruitment into the study. Gender-based focus group sessions were conducted for the inner city participants but individual interviews were conducted for those who came to the main TB clinic or were hospitalized. Facilitators used open-ended questions and participants were asked to discuss their experiences of being diagnosed with tuberculosis, what impact it had on their lives, issues around adherence to anti-TB medications and information pertaining to their experience with side effects to these medications. All data were audio-recorded, transcribed verbatim, and analyzed using constant comparative analysis.

RESULTS

39 patients with active TB participated. The mean age was 46.2 years (SD 18.4) and 62% were male. Most were Canadian-born being either Caucasian or Aboriginal. Four themes emerged from the focus groups and interviews. The first describes issues related to the diagnosis of tuberculosis and sub-themes were identified as 'symptoms', 'health care provision', and 'emotional impact'. The second theme discusses TB medication factors and the sub-themes identified were 'adverse effects', 'ease of administration', and 'adherence'. The third theme describes social support and functioning issues for the individuals with TB. The fourth theme describes health behavior issues for the individuals with TB and the identified sub-themes were "behavior modification" and "TB knowledge."

CONCLUSION

Despite the ability to cure TB, there remains a significant impact on QOL. Since much attention is spent on preventative or curative mechanisms, the impact of this condition on QoL is often not considered. Attention to the issues experienced by patients being treated for TB may optimize adherence and treatment success.

Sociocultural aspects of tuberculosis: a literature review and a case study of immigrant tuberculosis

The resurgence of tuberculosis in recent years has obliged us to reconsider the existing explanations of the disease. Whereas biomedical literature tends to explain tuberculosis in terms of biological factors (e.g., bacterial infection), social scientists have examined various cultural, environmental, and politico-economic factors. In this paper, sociocultural approaches to tuberculosis are reviewed according to their emphasis on cultural, environmental, and politico-economic factors. Then how the public health establishment considers biological, cultural, environmental and politico-economic factors will be examined through a case study of immigrant tuberculosis. While public health facilities emphasize biological factors in the control of immigrant tuberculosis, an ethnographic study of tuberculosis among Chinese immigrants in New York City provides detailed contexts that illustrate the cultural, environmental, and politico-economic forces shaping tuberculosis and supports an emerging theorization of tuberculosis that encompasses a heterogeneous collection of factors. Finally, a number of implications for public health interventions will be discussed.

Perceptions and experiences of health care seeking and access to TB care--a qualitative study in rural Jiangsu Province, China

This study aims to obtain an in-depth understanding of factors that influence the health seeking behavior of TB patients, and access to tuberculosis (TB) care in counties with or without National TB Control Program (NTP) in rural China. Sixteen focus group discussions (FGDs) composed of TB patients and health care providers were held. Content analysis showed perceptions that financial difficulties influence health care-seeking behavior of TB patients in both program and non-program counties. Female and elderly patients were perceived to be more reluctant to seek health care and to seek care for cough from village health stations rather than general hospitals. Many TB patients said they could not afford the cost of TB care, even where services were subsidized. Fee-for-service incentives of health care providers and their ability to make a correct TB diagnosis were also perceived to influence patient access to TB care. Inappropriate treatment of cough patients was perceived to increase the risk of missing smear-positive diagnoses.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part II: determinants operating at environmental and institutional level

This review summarises a wide range of evidence about environmental and institutional factors that influence vulnerability to malaria, tuberculosis, and HIV infection. By combining this information with that obtained on factors operating at individual, household, and community level, we have identified potential common strategies for improving resilience to all three diseases simultaneously. These strategies depend on collaborations with non-health sectors and include progress in rapid access to funds, provision of education about disease transmission and management, reduction of the burden on carers (predominantly women), and improvement in the quality of health services.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

Pathways to treatment for tuberculosis in Bali: patient perspectives

The authors explored treatment-seeking behavior among people with tuberculosis (TB) in Bali, Indonesia. They conducted in-depth interviews with 5 people who had been diagnosed with TB and 6 people who were suspected of having TB but who had not yet received a diagnosis. Participants reported frequent delays in obtaining a diagnosis of TB and obtaining adequate treatment. The authors describe issues associated with treatment-seeking behavior using the following five main themes: awareness of TB-causes, symptoms, and seriousness; influence of others; treatment quality; treatment barriers and default; and stigma and fear. Their findings reinforce the importance of a comprehensive TB control program that provides quality diagnostic and treatment services, and patient and community education, and enables patient involvement in treatment.

Quality of life in tuberculosis: patient and provider perspectives

Tuberculosis (TB) is a persistent problem in the United States; however, little is known about its impact on functioning and quality of life (QOL) among people with TB. The purpose of this study is to describe the impact of TB on patients' QOL by using focus groups to assess the domains of QOL that are affected. Participants included patients (n = 10) who received treatment for active TB and physicians (n = 4) and nurses (n = 9) caring for patients with TB at a public health clinic in Baltimore, Maryland. TB affected all predicted domains of QOL, including general health perceptions, somatic sensation, psychological health, spiritual well-being, and physical, social and role functioning. Social stigmatization, isolation, pill burden, long duration of therapy, sexual dysfunction, loss of income, and fear were additional specific problems related to TB. Surprisingly, 11% (33) of the comments described benefits of TB illness, including increased spirituality and improved life perspectives. In addition, four additional QOL domains and three elements of treatment specific to TB which substantially impact QOL were identified. While patients and clinicians both identified issues in many areas of QOL, only patients mentioned the impact on sexual function, spirituality and improved life perspectives. Despite available curative therapy, TB and its treatment still have significant short and long-term consequences on patients' QOL.

Critical reflections on evidence, ethics and effectiveness in the management of tuberculosis: public health and global perspectives

Background

Tuberculosis is a major cause of morbidity and mortality globally. Recent scholarly attention to public health ethics provides an opportunity to analyze several ethical issues raised by the global tuberculosis pandemic.

Discussion

Recently articulated frameworks for public health ethics emphasize the importance of effectiveness in the justification of public health action. This paper critically reviews the relationship between these frameworks and the published evidence of effectiveness of tuberculosis interventions, with a specific focus on the controversies engendered by the endorsement of programs of service delivery that emphasize direct observation of therapy. The role of global economic inequities in perpetuating the tuberculosis pandemic is also discussed.

Summary

Tuberculosis is a complex but well understood disease that raises important ethical challenges for emerging frameworks in public health ethics. The exact role of effectiveness as a criterion for judging the ethics of interventions needs greater discussion and analysis. Emerging frameworks are silent about the economic conditions contributing to the global burden of illness associated with tuberculosis and this requires remediation.

Involving private practitioners and chest physicians in the control of tuberculosis

SETTING

Private practitioners including chest physicians are often an important obstacle to having a successful National Tuberculosis Programme (NTP) in low- and middle-income countries. This complicated situation has been present in most of the Latin American countries for many years.

OBJECTIVE

To design an intervention model to obtain collaboration and integration of specialist physicians in the actions of the NTP.

DESIGN

In 1998, the IUATLD designed a special interactive model of training courses, to be held in an important number of Latin American countries. This intensive (25h in 3 days) course was named "Importance of the role of chest physicians and their integration in NTP strategies". At the end of each course, the participants were invited to sign a series of agreements concerning controversial topics that had blocked collaboration in the past.

RESULTS

This course, adapted to the situation of the different countries, has been held 17 times in 9 different countries. So far, nearly 600 specialist physicians have been trained with this special model, and all of them have signed important agreements on future collaboration.

CONCLUSION

There has been an important improvement in integrating these specialist physicians into the actions of the NTPs. This intervention has contributed to a substantial improvement of tuberculosis control in the last 4 years in Latin America.

Private practitioners and tuberculosis control in the Philippines: strangers when they meet?

OBJECTIVE

To investigate the knowledge, attitudes and perspectives of the Filipino private physicians (PPs) on tuberculosis (TB) control issues in the Philippines and their implications for future governmental public health policies.

DESIGN

Cross-sectional telephone survey from June to October 2001.

PARTICIPANTS

In each of the 78 provinces of the Philippines we randomly selected 10 PPs from the provincial capital city, five PPs from an urban centre with more than 50,000 population, and one PP from 15 rural villages with <50,000 population, making a total of 30 PPs per province. These data were complemented with information from focus group discussions with health workers and policy makers working in TB control, and through personal interviews with PPs.

RESULTS

We interviewed 1355 (57.9%) of 2340 PPs identified. TB was diagnosed mainly through X-ray (87.9%) and usually treated with inappropriate regimens of anti-TB drugs (89.3%). The PPs did not follow-up their TB patients, did not trace the defaulters (97.9%) and did not identify contacts (91.4%). Only 24.2% knew the National Tuberculosis Programme (NTP) policies in depth. They defined the NTP's weakest points as diagnosis through sputum microscopy (59.2%) and the management of smear negative patients (29.7%). Most PPs were willing to collaborate with the NTP (83.3%) provided they were paid (38.4%). More than a half (51.5%) objected to obligatory reporting of new TB cases. The PPs based their success in attracting TB patients to their offices on confidentiality (46.1%) and on the kind treatment and flexibility given (43.7%).

CONCLUSIONS

Diagnosis and treatment of TB patients is a daily issue for the PPs in the Philippines, although they did not follow usually the NTP guidelines. The majority of the PPs wished to collaborate with the NTP provided they were paid.

A literature review of the problems of delayed presentation for treatment and non-completion of treatment for tuberculosis in less developed countries and ways of addressing these problems using particular implementations of the DOTS strategy

Tuberculosis is the cause of a large burden of disease in less developed countries. With the development of drug resistance and the co-epidemic of HIV, tuberculosis has already started to make a comeback in wealthier countries. The WHO's solution to this global tuberculosis epidemic is the DOTS strategy, the implementation of which presents many problems. The two issues most common to the majority of locations are delay in presentation for treatment and non-completion of treatment. This review looks at the reasons for these problems in the less developed world, and addresses some solutions. The main reasons for delayed presentation are: a lack of understanding about TB; the stigma associated with the disease; the inaccessibility of treatment; and a preference for private practitioners. The main reasons for non-completion of treatment are: the stigma of the disease; a lack of information; dissatisfaction with the treatment and its delivery; and inaccessibility of treatment. Successful implementations of the DOTS strategy need to address all these issues. There is little evidence that DOT enhances treatment completion unless combined with other strategies. Community-based, patient-orientated DOTS appears to be an appropriate way of addressing many of these issues. The involvement of volunteers in community-based strategies is common, but needs more research in order for this strategy to realise its full potential.

The limits to patient compliance with directly observed therapy for tuberculosis: a socio-medical study in Pakistan

Complying with the prescriptions of the directly observed therapy (DOT), one of the components of the Global Tuberculosis Programme of the WHO, is problematic for many patients. The factors leading to patient (non-) compliance with DOT are placed in a structural equation model. The study is based on a survey carried out in one general hospital in the Punjab province of Pakistan, amongst all sputum positive pulmonary TB patients (n = 621) who arrived at the TB unit from September 1997 to October 1998. The tested sequence of manifest variables and latent constructs shows that the social stratification perspective has to be extended by the stigmatization perspective. The advantages of universally applying DOT will increase even further when the latter perspective is involved in the analysis of non-compliance. There is a real danger that the patients reached by selective DOT will be stigmatized even more.

The relationship between disease control strategies and health system development: the case of TB

This paper focuses on the lack of dialogue and policy consonance between those taking the lead in health systems change and those developing specific disease control strategies. In the first part, the origins and characteristics of this situation are explained using, as an example, TB control. Attention is then paid to the development of disease control friendly health systems. Four aspects of policy development are analysed paying particular attention to TB control: analysis of policy context, mechanisms for collaboration between policy actors; agreement on decision-making processes; development of common aims and objectives. Although the focus is on TB control, the principles illustrated carry some relevance for other disease control programmes.

Placing gender at the centre of health programming: challenges and limitations

In this paper we argue that a gender analysis is fundamental to health and health planning. We begin with a definition of gender and related concepts including equity and equality. We discuss why gender is key to understanding all dimensions of health including health care, health seeking behaviour and health status, and how a gender analysis can contribute to improved health policies and programming. Despite the many reasons for incorporating gender issues in health policies and programmes many obstacles remain, including the lack of attention to gender in the training of health professionals and the lack of awareness and sensitivity to gender concerns and disparities in the biomedical community. We argue that the key to placing gender values firmly in place in Health for All renewal is a change in philosophy at all levels of the health sector and suggest ways in which such a change can be implemented in the areas of policy, research, training and practical programmes and interventions.

Gender inequalities in tuberculosis: aspects of infection, notification rates, and compliance

Tuberculosis (TB) kills approximately 1 million women per year and it is estimated that almost 1 billion women and girls are infected with TB worldwide. Gender aspects of TB have been neglected in the research, and little attention is given to gender in TB-control programs. This review brings together the most important publications on gender and TB during 1999 and 2000 and illuminates areas where gender has an impact on the disease and its control. Even though only a limited number of publications on gender aspects of TB are available, some interesting findings were presented during the past year. Studies from Vietnam have shown that women with pulmonary TB are diagnosed on average 2 weeks later than men because of delays from the health care provider. In a study of persons with cough it was found that men were given sputum examinations more often than women. These and other findings are discussed in relation to the hypothesis that women with TB are under-notified.

Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan

BACKGROUND

DOTS is the control strategy for tuberculosis promoted by WHO. Pakistan is currently developing its National Tuberculosis Programme, and requires guidance on types of direct observation of treatment appropriate for the local conditions. We did a randomised trial to assess the effectiveness of different packages for tuberculosis treatment under operational conditions in Pakistan.

METHODS

We enrolled 497 adults with new sputum-positive tuberculosis. 170 were assigned DOTS with direct observation of treatment by health workers; 165 were assigned DOTS with direct observation of treatment by family members; and 162 were assigned self-administered treatment. The trial was done at three sites that provide tuberculosis services strengthened according to WHO guidelines for the purposes of the research, with a standard daily short-course drugs regimen (2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 6 months of isoniazid and ethambutol). The main outcome measures were cure, and cure or treatment completion. Analysis was by intention to treat.

FINDINGS

Within the strengthened tuberculosis services, the health-worker DOTS, family-member DOTS, and self-administered treatment strategies gave very similar outcomes, with cure rates of 64%, 55%, and 62%, respectively, and cure or treatment-completed rates of 67%, 62%, and 65%, respectively.

INTERPRETATION

None of the three strategies tested was shown to be superior to the others, and direct observation of treatment did not give any additional improvement in cure rates. The effectiveness of direct observation of treatment remains unclear, and further operational research is needed.