From careless consumptives to recalcitrant patients: the historical construction of noncompliance

Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing

Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.

Encounters between medical and lay knowledge in therapeutic patient education. A qualitative study based on an oral chemotherapy program

OBJECTIVES

The growing number of cancer patients treated with Oral Chemotherapy (OC) at home, is prompting many healthcare centers to develop Therapeutic Patient Education (TPE) programs. This study aimed to 1) describe the different forms of knowledge shared and learned in these programs, and 2) better understand how self-care and psychosocial skills are promoted in the TPE context.

METHOD

This study used qualitative data from the French "ONCORAL" program. Data collection was conducted with non-participant observations. The corpus comprised 42 TPE sessions.

RESULTS

Analysis highlighted that TPE specifically helps patients' functional health, revealed the medical expectations and social norms that shape the patient's role, and exposed the difficulties faced by the patient when acquiring self-care skills. Self-care skills and psychosocial skills also appeared to be mutually dependent in the context of TPE.

CONCLUSION

TPE programs which focus more on developing medical knowledge inevitably give less importance to psychosocial skills. Yet the recognition and promotion of the latter in TPE may lead to positive coping strategies related to medical outcomes, such as adherence.

PRACTICE IMPLICATION

Dedicated TPE program objectives for patients undergoing oral chemotherapy should recognize not only the value of medical knowledge but also of lay knowledge.

Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler

Background

Research globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.

Aim

To develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.

Setting

A rural primary health care clinic in the Eastern Cape, South Africa.

Methods

Pictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.

Results

The number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.

Conclusion

The tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

How patients navigate the diagnostic ecosystem in a fragmented health system: a qualitative study from India

Background: Depending on a country’s diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the ‘test and treat’ loop.

Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis.

Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns.

Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices.

Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services.

Integrating innovations: a qualitative analysis of referral non-completion among rapid diagnostic test-positive patients in Uganda's human African trypanosomiasis elimination programme

BACKGROUND

The recent development of rapid diagnostic tests (RDTs) for human African trypanosomiasis (HAT) enables elimination programmes to decentralise serological screening services to frontline health facilities. However, patients must still undertake multiple onwards referral steps to either be confirmed or discounted as cases. Accurate surveillance thus relies not only on the performance of diagnostic technologies but also on referral support structures and patient decisions. This study explored why some RDT-positive suspects failed to complete the diagnostic referral process in West Nile, Uganda.

METHODS

Between August 2013 and June 2015, 85% (295/346) people who screened RDT-positive were examined by microscopy at least once; 10 cases were detected. We interviewed 20 RDT-positive suspects who had not completed referral (16 who had not presented for their first microscopy examination, and 4 who had not returned for a second to dismiss them as cases after receiving discordant [RDT-positive, but microscopy-negative results]). Interviews were analysed thematically to examine experiences of each step of the referral process.

RESULTS

Poor provider communication about HAT RDT results helped explain non-completion of referrals in our sample. Most patients were unaware they were tested for HAT until receiving results, and some did not know they had screened positive. While HAT testing and treatment is free, anticipated costs for transportation and ancillary health services fees deterred many. Most expected a positive RDT result would lead to HAT treatment. RDT results that failed to provide a definitive diagnosis without further testing led some to question the expertise of health workers. For the four individuals who missed their second examination, complying with repeat referral requests was less attractive when no alternative diagnostic advice or treatment was given.

CONCLUSIONS

An RDT-based surveillance strategy that relies on referral through all levels of the health system is inevitably subject to its limitations. In Uganda, a key structural weakness was poor provider communication about the possibility of discordant HAT test results, which is the most common outcome for serological RDT suspects in a HAT elimination programme. Patient misunderstanding of referral rationale risks harming trust in the whole system and should be addressed in elimination programmes.

Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions

Objective

In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP‐led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care.

Design

An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In‐depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data.

Results/Findings

Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health‐care providers. Participants discussed how patients and providers learn from one another to facilitate self‐management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers.

Discussion

NP‐led GMVs are a method of care delivery that harness NPs’ professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient‐centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team‐based and patient‐centred health‐care objectives and may disrupt inherent power differentials that exist in primary care.

The myth of the total institution: Written narratives of patients' views of sanatorium care 1908-1959

Drawing on written narratives by 72 former sanatorium patients, this article explores, from patients' perspectives, the nature of the relationships between patients and staff in a Swedish sanatorium during the first half of the twentieth century. These narratives are discussed in the context of the total institution. This article suggests that this phenomenon was marked by inconsistencies that can be understood in terms of its situational and contradictory characteristics. Simultaneously, these narratives are in opposition to the assumption of the static and powerless patient adapted only to suit the logic of the institution.

SOCIAL, HISTORICAL AND CULTURAL DIMENSIONS OF TUBERCULOSIS

Tuberculosis (TB) researchers and clinicians, by virtue of the social disease they study, are drawn into an engagement with ways of understanding illness that extend beyond the strictly biomedical model. Primers on social science concepts directly relevant to TB, however, are lacking. The particularities of TB disease mean that certain social science concepts are more relevant than others. Concepts such as structural violence can seem complicated and off-putting. Other concepts, such as gender, can seem so familiar that they are left relatively unexplored. An intimate familiarity with the social dimensions of disease is valuable, particularly for infectious diseases, because the social model is an important complement to the biomedical model. This review article offers an important introduction to a selection of concepts directly relevant to TB from health sociology, medical anthropology and social cognitive theory. The article has pedagogical utility and also serves as a useful refresher for those researchers already engaged in this genre of work. The conceptual tools of health sociology, medical anthropology and social cognitive theory offer insightful ways to examine the social, historical and cultural dimensions of public health. By recognizing cultural experience as a central force shaping human interactions with the world, TB researchers and clinicians develop a more nuanced consideration of how health, illness and medical treatment are understood, interpreted and confronted.

Domestic experiments: familial regimes of coping with childhood asthma in New Zealand

In this article, I examine the self-positioning of many New Zealand mothers of children with asthma as parent-experts whose authority supersedes that of implementing the self-management strategies advocated by medical professionals. In a socio-political context that emphasizes neoliberal values of autonomy and self-responsibility, these parent-experts experiment with a variety of pharmaceutical regimes, determining familial modes of care that privilege the achievement of what they consider to be 'normal childhoods.' While some families accept asthma as a chronic condition and encourage children to adopt standardized, daily preventative regimes, others craft alternative strategies of pharmaceutical use that allow them to experientially maintain asthma as a sporadic and temporary, if frequent and sometimes dramatic, interruption of everyday life. Childhood asthma care practices are thus not only vested in kinship networks, but often arise out of familial-based experiments whose goal is to determine regimes that enable the preservation of 'normality.'

Asthma control: the right inhaler for the right patient

Inhaled therapy is the cornerstone of asthma management in that it optimizes the delivery of the medication to the site of action. The effectiveness of inhaled therapy is affected by the correct choice of the device and proper inhalation technique. In fact, this influences the drug delivery and distribution along the bronchial tree, including the most peripheral airways. In this context, accumulating evidence supports the contribution of small airways in asthma, and these have become an important target of treatment. In reality, the "ideal inhaler" does not exist, and not all inhalers are the same. Advances in technology has highlighted these differences, and have led to the design of new devices and the development of formulations characterized by extrafine particles that facilitate the distribution and deposition of the drug particles along the respiratory tract. In addition, efforts have been made to implement adherence to chronic treatment, which translates into clinical benefit. Taken together, the optimal control of asthma depends on the drug that is selected, the device that is employed and the removal of factors that reduce patient's adherence to therapy.

Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies

Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness's association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.

Logiques divergentes et confrontations des savoirs

La prise irrégulière ou le refus d’un traitement peuvent parfois être perçus comme une déviance ou une conduite anormale et modifier la relation entre le soignant et son patient. Le rôle des soignants consiste alors à ramener vers la norme les individus ne s’y conformant pas. La non-observance thérapeutique (la conduite) est un phénomène multidimensionnel. Néanmoins, la non-observance nécessite également d’interroger le point de vue des patients, c’est-à-dire l’adhésion thérapeutique (l’attitude). L’exploration des différentes rationalités qui modulent les trajectoires thérapeutiques des patients permet de saisir la complexité du lien entre les conduites et les attitudes. En nous appuyant sur une ethnographie réalisée à la Clinique de tuberculose d’un hôpital pédiatrique à Montréal (Québec, Canada), nous présentons une étude de cas qui permet d’approfondir la compréhension de l’observance (ou non) et de l’adhésion (ou non) thérapeutique. Des familles de l’Europe de l’Est sont au coeur de la réflexion. Certaines caractéristiques de ces familles mettent en avant des profils sociodémographiques qui modifient la rencontre clinique. Plus spécifiquement, l’accent est placé sur la pluralité des rationalités et des divergences au sein de la biomédecine, qui vient teinter les dynamiques relationnelles entre les familles et l’équipe soignante tout en exposant le déplacement des frontières entre les savoirs profanes et experts.

The politics of securing borders and the identities of disease

This article compares the policies adopted by Britain, France and Germany to cope with health threats thought to be posed by entrants and migrants and explains why these governments screened at their borders for tuberculosis but not for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). In order to understand these outcomes, we must recognise that diseases acquire durable identities, conditioned by collective imaginaries and institutional contexts when they first come to attention, which bias subsequent decisions, notably about how to balance the value of mandatory testing against the rights of the individual.

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

BACKGROUND

Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence-related beliefs or behaviours for individual patients.

AIMS

To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy.

METHODS

Patients aged ≥ 14 years with doctor-diagnosed asthma who were prescribed inhaled corticosteroid/long-acting β(2)-agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side-effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses.

RESULTS

99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self-reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=-0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R(2) = 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side-effects; the one-third of patients who reported experiencing side-effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015).

CONCLUSIONS

This study identified several specific beliefs and behaviours which clinicians could use for initiating patient-centred conversations about medication adherence in asthma.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Prevalence of multi-drug resistant tuberculosis in Karachi, Pakistan: identification of at risk groups

Multidrug-resistant tuberculosis (MDR-TB) is a possible threat to global tuberculosis control. Despite a disease prevalence of 263/100 000 population Pakistan lacks information on prevalence of drug resistant TB. Our objective was to estimate prevalence of MDR and associated risk factors in patients with pulmonary tuberculosis in Karachi. Six hundred and forty consenting adult patients were enrolled from field clinics from July 2006 to August 2008 through passive case finding. Prevalence of MDR-TB with 95% confidence interval (CI) was calculated with Epi-Info. Logistic Regression analyses were performed for risk factors associated with MDR. Overall MDR rate was 5.0%, 95% CI: 3.3-6.6% (untreated 2.3%, treated 17.9%). Mean age was 32.5 (+/-15.6) years and there were 292 (45.6%) females and 348 (54.4%) males. Factors independently associated with MDR were: female gender (OR 3.12; 95% CI: 1.40-6.91), and prior history of incomplete treatment (OR 10.1; 95% CI: 4.71-21.64). Ethnic groups at higher risk for MDR included Sindhis (OR 4.5; 95% CI: 1.42-14.71) and Pashtoons (OR 3.6, 95% CI: 1.12-11.62). This study reports an overall MDR rate of 5.0% in our study population. It further highlights the need for MDR prevention through re-focusing Directly Observed Treatment, Short-course DOTS delivery with emphasis on women and certain high risk sub groups.

Specialty care use in US patients with chronic diseases

Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.

Compliance and concordance during domiciliary medication review involving pharmacists and older people

Medication review is an advanced service registered pharmacists can now offer patients in the UK. This in-depth study of pharmacist-older patient communication during domiciliary medication review encounters examines how the interactions are constructed by participants and the influence of the compliance paradigm on the interaction. Twenty-nine observed, taped and transcribed consultations were analysed using discourse analysis. Ethnographic-style interviews in the field with pharmacists, follow-up interviews with patients and feedback workshops with pharmacists allowed interpretations to be tested and strengthened. The findings presented here use discourse analysis to look at the task-driven nature of the medication review encounters. The analysis explores the interactional format of three over-lapping phases of the consultations: (i) introductions and agenda setting; (ii) screening and testing patients' ability to comply; and, (iii) investigating over-the-counter medicines. Analysis suggests that a dominant compliance paradigm encourages pharmacist-led encounters with patients failing to engage in the medication review process. Little evidence of two-way reciprocated discussion or concordance was evident. The strategic nature of the discourse of compliance heard in these medication review encounters and its effect on older patients are discussed. The paper concludes with a consideration of the implications for pharmacy practice and policy development.

Time, self and the medication day: a closer look at the everyday work of 'adherence'

This article examines the everyday work of participating in pharmaceutical treatment for HIV infection in the context of urgent calls for adherence. Drawing on interviews and focus-group conversations with people taking antiretroviral drugs, the analysis explicates the work that goes into striving for adherence. What comes into view is a form of time work that brings about a temporary alignment between the inner experience of time, standard clock time, and the requirements of the medication schedule. Time work is largely cognitive; the pills, however, must actually be swallowed to complete the dose, occasioning, for some people, additional work to suppress or refashion emotional responses of anger and resistance. Both the time work and the emotional work of taking antiretroviral drugs draw people into forms of self work, including self-examination and self-adjustment, as they develop strategies for 'doing adherence'.

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.

Senator Bill Frist and the medical jeremiad

This essay analyzes Senator Bill Frist's 2001 address to the American Society of Thoracic Surgeons. The author argues that the address represents an attempt to reframe physicians' political identity to authorize more active participation by them. Frist authorizes and demands such participation through the construction of a medical jeremiad. He argues that American physicians must have greater involvement to preserve the health of the body politic and to reassert physician control over the biomedical system. Although Frist's arguments are built on an apparently democratic form of address, his jeremiad illustrates aristocratic possibilities in medico-political rhetoric.

Patient accounts for noncompliance with diabetes self-care regimens and physician compliance-gaining response

The purpose of this study was to identify diabetics' accounts for medical noncompliance, physicians' compliance-gaining strategies elicited in response to those accounts, and to examine the relationship between accounts and compliance-gaining strategies. Telephone surveys of diabetics from Kentucky and Tennessee assessed patient perceptions of physician-patient communication during their last diabetes treatment-related appointment. Eighty-four patients were able to provide categorical data for analysis. Patient account strategies for noncompliance were coded as concessions, excuses, justifications, and refusals. Physician compliance-gaining strategies were coded as positive-regard, negative-regard, or neutral-regard strategies. Results showed the most common patient account was concession (33%), then excuse (23%), justification (22%), and refusal (7%). The most common physician compliance-gaining strategy was neutral regard (54%), then positive regard (31%) and negative regard (15%). Results also indicated that patient account and physician compliance-gaining strategy were related. Specifically, concession accounts from patients elicited a subsequent neutral-regard compliance-gaining strategies from the physician in 76% of concession cases. Results also show that justifications were most likely to elicit neutral- (52%) or positive-regard (43%) strategies. Implications for physician practice and future research are discussed.

A social disease/a social response: lessons in tuberculosis from early 20th century Chile

During the 1930s, Chile reported the world's highest mortality rate due to tuberculosis. In this pre-antibiotic era, the attention of the biomedical community frequently turned to the underlying social inequalities and deficiencies that created conditions of heightened risk for Chile's rapidly expanding working class. With the recognition that crowded housing, chronic malnutrition and substandard working conditions fostered an environment in which the disease developed and spread with virulent rapidity, physicians frequently became vocal advocates for widespread and significant social reform. However, by the time of the introduction of efficacious pharmaceutical agents in the 1940s and with the overall rapid development of biomedicine in the mid-20th century, the larger medical discourse became more rigidly defined and characterized by the promotion of the new antibiotics and treatments. These factors increased the depth of the self-defined medical territory but substantially reduced its breadth. Accompanying this shift was an increasing focus on individual behaviors that were seen as deficient and were both socially censored and used as explanations for increased susceptibility. In the midst of the current worldwide epidemic of tuberculosis, this disease and its epidemiological pattern heightens our awareness of the significance and consequences of global inequalities. It also draws our attention to the importance of intervention within the social conditions from which these patterns emerge.

The beliefs of people with chronic pain in relation to 'important' treatment components

BACKGROUND

The beliefs of people with chronic pain (service users) about the importance of treatment components offered through both multidisciplinary and other types of chronic pain programmes are not widely examined in the literature.

AIM AND METHOD

As part of a wider research study of the congruence between what service providers and service users believe to be important treatments for chronic pain, members of three chronic pain support groups located in the North-West region of England were surveyed. The survey asked service users' opinion about whether specific treatment components are important or not important for people with chronic pain. The survey also included Skevington's Beliefs About Pain Control Questionnaire (BPCQ) that measures beliefs in the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events.

RESULTS AND CONCLUSION

Findings show that no treatment components were endorsed as important by more that 67% of the participants. Endorsements clustered around treatments that focused on self-management and biomedical interventions. A statistically significant relationship emerged between certain treatment components and BPCQ scores. These findings contribute to the growing cautions regarding standardised, 'one-size-fits all' treatment programs and the mistake of assuming people with pain form a homogenous group.

An ethnography of nonadherence: culture, poverty, and tuberculosis in urban Bolivia

The author conducted a focused descriptive ethnographic study of nonadherence with tuberculosis (TB) therapy among Aymara-speaking residents of the city of La Paz, Bolivia. A cohort of patient-informants was identified from the District III TB Control Registry of La Paz as having been nonadherent with their TB medication protocol. From June to August 1998, ethnographic material was collected through participant-observation and repeated interviews and visits in homes, workplaces, clinics, and the community. Ethnographic analysis revealed structural barriers to be more important than cultural differences in the production of nonadherence. Though informants maintained a variety of beliefs and practices related to Aymara medicine, the majority of patients were comfortable with a biomedical model of tuberculosis and maintained belief in the efficacy of antituberculosis chemotherapy and desire to finish treatment. Patients overwhelmingly cited hidden costs of treatments, poor access to care, ethnic discrimination, and prior maltreatment by the health system as reasons for abandoning treatment. These data suggest that overemphasis of cultural difference without exploration of other social dimensions of health care delivery can obscure a more practical understanding of nonadherence in marginalized populations.

Médicament et vieillesse

Cet article emprunte une approche socioculturelle de la problématique de la vieillesse par rapport au médicament. Il appréhende avec un regard critique le phénomène « médicament » à travers trois énoncés de relations : le « médicament-obligation » comme qualificatif de la relation des personnes âgées au médicament ; le « médicament-concession » en tant que trame de fond de la relation thérapeutique entre médecin et patient âgé ; le « médicament-compassion », enfin, comme métaphore du rôle des médicaments psychotropes en lien avec le statut de la vieillesse dans nos sociétés occidentales avancées.

The resurgence of disease: social and historical perspectives on the 'new' tuberculosis

The resurgence of tuberculosis is one of the most serious global public health challenges of the twenty-first century. This paper argues that the decline of tuberculosis since the nineteenth century is far better understood than its resurgence over the last twenty years. It is suggested that insights gained from the historical study of disease may provide a better analytical framework for understanding the contemporary dynamics of disease epidemiology than the current emphasis on the bio-medical and behavioural characteristics of individual patients. It is concluded that tuberculosis research requires a combination of advances in bio-medical knowledge with a broader understanding of the evolving relationship between disease and modern societies.

Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries

The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991-98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia. Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia.

Holding the patient

Successfully controlling tuberculosis will require that we fully understand all the factors involved in a patient's ability to comply with treatment as well as our assumptions about what compliance and noncompliance mean. Influences on patients' lives, such as poverty, conflict, political instability, and racial and gender inequalities, will have a great impact on the success or failure of treatment. TB services should be designed to provide the support that patients need to enable them to be cured.

Qigong Yangsheng as a complementary therapy in the management of asthma: a single-case appraisal

OBJECTIVES

Qigong Yangsheng, the health-promoting method of traditional Chinese medicine that combines movement, mental exercise, and breathing technique, is used in China for the therapy of bronchial asthma, and for some time now has been enjoying an ever-widening acceptance in the Western world as well. This pilot study investigates if Qigong Yangsheng could be used as a complementary therapeutic measure to treat asthma patients in a Western industrialized country.

DESIGN

Thirty asthma patients, with varying degrees of illness severity, were taught Qigong Yangsheng under medical supervision. They were asked to exercise independently, if possible, on a daily basis and to keep a diary of their symptoms for half a year including peak-flow measurements three times daily, use of medication, frequency and length of exercise as well as five asthma-relevant symptoms (sleeping through the night, coughing, expectoration, dyspnea, and general well-being). The concept of this study was based on a single-case research design series with baseline, one teaching phase, a phase of self-practice and a refresher teaching course. A 4-week follow-up period was carried out in the same season as the original baseline phase 52 weeks later.

RESULTS

An improvement was indicated if subjects showed a decrease of at least 10 percent in peak-flow variability between the 1st and the 52nd week. This occurred more frequently in the group of the exercisers (n = 17) than in the group of nonexercisers (n = 13) (p < 0.01 chi-square with Yates correction). When comparing the study year with the year before the study, there was improvement also in reduced hospitalization rate, less sickness leave, reduced antibiotic use and fewer emergency consultations resulting in reduced treatment costs.

CONCLUSION

Qigong Yangsheng is recommended for asthma patients with professional supervision. An improvement in airway capability and a decrease in illness severity can be achieved by regular self-conducted Qigong exercises.