Ethics of directly observed therapy for the control of infectious diseases

A scoping review of patient-centred tuberculosis care interventions: Gaps and opportunities

Tuberculosis (TB) is a leading cause of death globally. In 2015, the World Health Organization hailed patient-centred care as the first of three pillars in the End TB strategy. Few examples of how to deliver patient-centred care in TB programmes exist in practice; TB control efforts have historically prioritised health systems structures and processes, with little consideration for the experiences of people affected by TB. We aimed to describe how patient-centred care interventions have been implemented for TB, highlighting gaps and opportunities. We conducted a scoping review of the published peer-reviewed research literature and grey literature on patient-centred TB care interventions between January 2005 and March 2020. We found limited information on implementing patient-centred care for TB programmes (13 research articles, 7 project reports, and 19 conference abstracts). Patient-centred TB care was implemented primarily as a means to improve adherence, reduce loss to follow-up, and improve treatment outcomes. Interventions focused on education and information for people affected by TB, and psychosocial, and socioeconomic support. Few patient-centred TB care interventions focused on screening, diagnosis, or treatment initiation. Patient-centred TB care has to go beyond programmatic improvements and requires recognition of the diverse needs of people affected by TB to provide holistic care in all aspects of TB prevention, care, and treatment.

Surveillance or support: The experience of direct observation during tuberculosis treatment

Directly observed therapy (DOT) is a cornerstone of tuberculosis (TB) control. DOT has been criticised as paternalistic, but it has also been argued that the interaction with healthcare workers (HWs) can be a source of support for patients. We explored the experience of patients in antituberculosis treatment, with the aim of understanding the balance between surveillance and support from the recipient's point of view. We interviewed 27 patients in Tijuana, Mexico, employing narrative analysis to understand how participants made sense of their illness and their experience of DOT. We found a core narrative of biographic disruption and self-reconstruction, in which HWs helped participants to attribute a less negative meaning to TB. Interviewees accepted DOT's as necessary for other people to avoid treatment abandonment, but felt that in their case it was unnecessary. Only a few felt that DOT represented mistrust on the part of the HWs. We conclude that DOT can be a source of support when it is enacted in a patient-centred way. We discuss whether participants' lack of criticism of DOT is a case of adaptive preference, in the context of a power differential between patient and health system.

Tuberculosis is a threshold: the making of a social disease in post-Soviet Georgia

In this article I use Margaret Lock's concept of local biology as a standpoint to view tuberculosis as a threshold where distinctions between social and biological aspects of disease are negotiated. I conceptualize tuberculosis as a threshold in two ways: first as a passageway, and second as a space for navigating the limits of tolerance to therapeutics. The article is based on ethnographic research about responses to tuberculosis in post-Soviet Georgia. I focus on how health professionals and patients make claims to social aspects of illness by recuperating historical examples for tuberculosis treatment as a moral commitment to society, and in the context of emergent patient-centered treatment services.

Vínculo doente-profissional de saúde na atenção a pacientes com tuberculose

OBJETIVO: Avaliar o desempenho dos serviços de saúde no controle da tuberculose para o estabelecimento do vínculo entre doente e profissional de saúde no Município de Ribeirão Preto - SP, em 2007. MÉTODOS: Foi aplicado um questionário a 100 doentes, elaborado para atenção básica e adaptado para atenção à tuberculose, que contém dez indicadores de avaliação de vinculo. RESULTADOS: Mais de 60% dos doentes de cada unidade referiam que conversam sobre outros assuntos além da tuberculose com os profissionais da saúde, mais de 90% relataram ter tempo suficiente para esclarecer dúvidas sobre o tratamento. Mais de 50% dos doentes de cada ambulatório relataram procurar o médico quando necessitam de cestas básicas ou vale-transporte. CONCLUSÃO: A organização da assistência à tuberculose realizada por equipes especializadas nos Programas de Controle da Tuberculose apresentou indicadores favoráveis ao vínculo, o que pode contribuir para a identificação das necessidades e busca de soluções.

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.

Can I afford free treatment?: Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam

Vietnam has a well-organised National TB Control Programme (NTP) with outstanding treatment results. Excellent prospect of cure is provided free of charge. Still, some people prefer to pay for their TB treatment themselves in private clinics. This is a potential threat to TB control since no notification of cases treated in the private sector occurs, and there is no control of the effectiveness of treatment provided in private clinics. Using a qualitative approach within a grounded theory framework, this study explores health-seeking behaviour among people with TB, applying a specific focus on reasons for choices of private versus pubic health care providers. The study identifies a number of characteristics of private TB care, which both seem attractive to patients and at the same time contrast sharply with the structure of the NTP strategy. These include flexible diagnostic procedures, no administrative procedures to establish eligibility for treatment, flexible choices of drug regimens, non-supervised treatment (no DOT), no tracing of defaulters in the household, no official registration of TB cases and thus less threat to personal integrity. A possibility to demand individualised service through the use of fee-for-service payments directly to physicians also seems attractive to many patients. A number of the components of the NTP strategy that have been put in place in order to secure optimal public health outcomes are lacking in the private sector. A dilemma for TB control is that this seems to be an important reason for why many people with TB opt for private providers where quality of care is virtually uncontrolled. The global threat of TB has led to calls for forceful measures to control TB. However, based on the findings in this study it is argued that the use of rigid approaches to TB control that do not encompass a strong component of responsiveness towards the needs of individuals may be counterproductive for public health.