# TBLit001

Q1_Title:
Public and private providers' quality of care for tuberculosis patients in Kampala, Uganda

Q1_Author:
Nshuti, L., Neuhauser, D., Johnson, J., Adatu, F., & Whalen, C.

Q2_Key:
private providers; public providers; TB; Uganda; quality of care; diagnosis; treatment

Q3b_Both:
Information about the clinics, their operating practices and the qualification of the clinic directors were collected in this study.  Knowledge and perceptions about the National TB and Leprosy Control Program were also assessed.

Q6_ReQue:
To compare the appropriateness of tuberculosis care in private and public clinics, and the extent of the tuberculosis burden handled in the private sector.

Q10_AduIntl:
Ugandans (clinic owners and health care workers from Kampala, Uganda)

Q14_Desc:
To assess the quality of tuberculosis care in private clinics, the scope of care and capacity for the tuberculosis cases handled, the emergence of multi-drug resistance, and the effectiveness of tuberculosis control, and to compare them with the government clinics.

The scale used to measure appropriate care for tuberculosis included four components: diagnosis, treatment, follow-up, and reporting. Refer to Table 1 (p. 1007) for further details.

Q15_Outc:
A total of 114 clinics (104 private, 10 public) were surveyed in which 41% of the private clinics saw three or more new tuberculosis patients each month.  None of the public or private clinics met all standards for appropriate tuberculosis care.  In general, public clinics provided more appropriate care for TB patients than private clinics.  Only 24% of all clinics adhered to WHO-recommended treatment guidelines.  Public clinics, younger practitioners, and practitioners with advanced degrees were most likely to provide appropriate care for tuberculosis.

Q16_Limt:
The scale for measuring appropriate care may fail to capture the health care behaviors of practitioners.  Also, because the study was conducted in the urban area of Kampala City, the results may not be generalizable to the rural areas where there may be considerable differences in practice.  The comparison groups also were not the same size because the number of public clinics was fixed.  Finally, a reporting bias may have occurred if practitioners who refused access to their medical records reported inaccurate information.

Q17_Conc:
The private sector cares for many tuberculosis cases in Kampala.  The practices of private practitioners do not often meet the standards set by the Ugandan National TB Program or the WHO.

Q18_Recc:
Future studies of private practitioners should endeavor to link practice behaviors with treatment outcome.  

National TB training programs and other public or private institutions should consider new programs that offer continuing medical education for private practitioners to improve TB care and to increase awareness of national guidelines for TB care.


Q1_Title:
Factors Influencing Completion of Treatment Among Tuberculosis Patients in Mbarara District, Uganda

Q6_ReQue:
Objective:  A study of treatment outcomes among 1400 patients seen in the Mbarara district of Uganda in 1995 showed a very low compliance rate of 56%; this study attempted to look at operational factors that may be associated with this low compliance rate.

Q14_Desc:
In Uganda, a previous study showed a high defaulter rate of 50% among TB patients.  This study attempted to elucidate operational factors underlying this defaulting from anti-TB treatment with a view of suggesting remedial actions.  In the original 1995 study, the factors that were associated with enhanced compliance of treatment included being smear positive; previous TB treatment; use of short course chemotherapy (SCC); if patient returned for repeat smear; if patient did not change unit; and if patient did not change district.  Gender and age of patients were not associated with compliance.  District change appeared to enhance compliance.

Q15_Outc:
This study has identified two factors in a routine program that could be remedied to improve compliance.  The use of short course chemotherapy in improving compliance is well known.  In this study, the risk of defaulting among the standard chemotherapy group was 1.72 times compared to the SCC group.  Another very important determinant associated the default was change of patients from one health unit to another after the intensive phase of treatment.  This factor alone contributed more than 22 times the risk of default among those who changed a health unit compared to those who were treated at the same unit.  One way of remedying this is to treat TB patients under the care of one health unit which is nearest to their homes and on an ambulatory basis.

Several reasons may be advanced to explain why changing from one health unit to another after the intensive phase of therapy is associated with low completion rates of anti-TB treatment in Mbarara district.  First establishing good rapport between patient and health care provider may be more different if there are two health care providers instead of one.  Secon1d, providing the initial treatment far away from the patient’s home may add to low completion rates.  Hospitalization places significant strain on family life, especially if the patients the major bread-winner.  Third, the staff where the patients are referred after the intensive phase may not be as well trained in TB health education and counseling as the staff at TB diagnostic centers.  Finally, most patients are symptom-free after the intensive phase, and do not bother to report to the health units where they are referred, especially if they have to go through the ordeal of establishing rapport with new health staff.

Q17_Conc:
It is hypothesized that treating patients at one health unit nearest to the patient’s home will improve compliance.  There is, however, a need for further study to elucidate the particular psychosocial factors associated with compliance.


Q1_Title:
Factors Affecting Prescribed Medication Compliance of the Urban Homeless Adult

Q2_Key:
homeless, adherence, compliance, health belief model, nursing

Q6_ReQue:
The purpose of this study was to describe the perceived factors that enhance or diminish prescribed medication compliance of homeless adults.

Q7_TheoBas:
Stated theoretical basis:  health belief model

Q8_SampCom:
61 homeless adult males Black  (70.5%), White (14.8%) Hispanic (9.8%) Asian (3.3%) Other  (1.6%)

Q10_AduUSBrn:
mostly Black  (70.5%), White (14.8%) Hispanic (9.8%) Asian (3.3%) Other  (1.6%)

Q13_Comm:
Statistically significant findings were reported.

Q14_Desc:
This retrospective descriptive study was designed to describe factors that enhance or diminish prescribed medication compliance in the homeless population and to compare these factors with perceived health status.  Interviews were collected over an 8-month period from 61 urban homeless adults with medication prescribed for their health problems sheltered in downtown Los Angeles, CA.

Q15_Outc:
Findings revealed that more than two thirds of the sample reported their health status to be fair to poor.  Nearly one third reported compliance rates ranging from none of the time to half the time.  Deterrents to compliance included structural variables such as availability of drugs and lack of privacy and storage space.  Factors enhancing compliance included carrying the medications, being close to the health clinic and understanding the need for the medication.

Q16_Limt:
Small sample size; opportunistic sampling strategy.

Q17_Conc:
Many of the factors reported to enhance or diminish compliance are within the realm of professional practice.  Results of the study indicate the importance of assessing barriers and enhancers of health care delivery in the homeless population.  In terms of nursing practice, by assessing health status and identifying factors that can contribute to non-compliant behavior, the health care professional will be better equipped to circumvent potential deterrents to the prescribed treatment plan.

Q18_Recc:
While the homeless are difficult to treat, tailoring health care delivery based on knowledge of enhancers and deterrents to prescribed therapy is essential. The present findings should provide a stimulus for further research in which prospective and intervention designs are undertaken to facilitate compliance.  While nurses often use Becker’s health belief model as a framework, considerations should be provided for its extension when the dimensions of concern are no longer addressed by the theoretical framework in use.


Q1_Title:
Compliance Versus Adherence: Just a Matter of Language? The Politics and Poetics of Public Health

Q1_Pages:
213-233. Singapore: Imperial College Press

Q2_Key:
compliance, adherence, TB, DOT, social science, discourse, patient, doctor

Q6_ReQue:
This chapter is an exploration, not of the effects of tuberculosis on people, but of the effects of history, language and culture on the ways in which people affect tuberculosis.

Q7_TheoBas:
This chapter is derived from the theoretical fashions of our current post-structure/post-modern world.

Q14_Desc:
The chapter addresses the discursive trail that has led ‘us’ to the reinvention of directly observed therapy not as a but as the gold standard approach to the ‘eradication’ of tuberculosis.  This chapter will question the foundations on which this ‘gold standard’ was built, as well as the appropriateness of eradication as a goal in public health.

Q15_Outc:
‘Compliance’ is an important area of overlap between the social and biomedical sciences.  Two social science themes have emerged as the source of the compliance problem:  doctor-patient relationship and patient’s health belief.  The introduction of DOTS and its aggressive marketing as the central feature of the WHO’s strategy, may have the effect of improving ‘compliance’ in some patients, but it does so without respecting patient agency and it may actually reinforce – or at least does nothing to redress - the fundamental issues underlying the persistence of tuberculosis in populations:  structural violence and social inequality.

Q17_Conc:
While social science perspectives endeavor to take patient perspectives and realities into account, they ultimately fail to overcome the assumptions about power, knowledge, legitimacy and agency, which are embedded in the discourse itself.   In acknowledging the power of language, as well as the power of patients, a number of writers have attempted to once again steer the course of compliance discourse in a more meaningful and equitable direction.  On the surface, simply replacing the word compliance with the word adherence will not create the desired change in meaning/emphasis/implication.  A trend among some social scientists is to bring our understanding of ‘adherence’ into articulation with our growing understanding of social inequalities and their impacts on health.

Q18_Recc:
The commitment of governments and health care structures to supporting this aim (DOTS) figure centrally. Oddly, however, DOT has become its marketing focus.  The reason for this would be an interesting avenue of research.

What is needed is a shift away from the reductionist tendencies of biomedicine.  It is time for the scientific community to turn the mirror inward, to look more critically at our own ‘beliefs and behaviors’ in relation to infectious disease; our own structure of control; and our assumptions about power: ours and that of the individuals and communities we are trying to support.  The time has come for us to accept the limits of our control over this microbe and to ask difficult questions, moral questions about how we may learn to live with it, and each other in a more realistic, creative and healthy way.


Q1_Title:
The resurgence of tuberculosis in the tropics: Improving tuberculosis control--social science inputs

Q1_Journal:
Transactions of the Royal Society of Tropical Medicine and Hygiene

Q2_Key:
Control, support, social science, community, partnership, DOTS

Q6_ReQue:
Hypothesis:  Research addressing the social, economic, and environmental factors that influence people’s lives can support change within TB programs and policies, enabling them to meet more effectively communities’ health needs.

Q14_Desc:
Public health has for long been dominated by the notion of “control.”  However, social science research on tuberculosis in the tropics indicates that policies and programs that take “control” as their primary focus may fail to met the health needs of patients and their communities.  The author argues that research and programs meet the public health goal of lowering the prevalence of disease in populations by forging and cementing partnerships that take the support and care of patients as their focus.

According to the author, a social science approach understands the patient and his/her experience, choices, needs, etc., as being nested within many layers of context.  Research that can be useful to programs and policy will need to address these five aspects:  individual patients, households, communities, health services, and policy.

Q15_Outc:
Research employing a qualitative approach will address key questions at each level of context.  Some of these question are outlined below:
1)  Document patient experiences.  When are symptoms serious enough to seek treatment outside the home?  What does “serious enough” mean and how/why is it different for one person than another?
2)  Explore the larger household and community contexts of these experiences.  What perceptions and knowledge about TB prevail in this community?  How is treatment-seeking for TB similar to or different from treatment-seeking for other conditions?
3)  Map and assess the health services landscape.  What is the range of treatment options?
4)  Policy-makers and donors.  How was national policy made and instituted?  Who finances the program and what are their interests?

Q17_Conc:
The findings from the operational research conducted in Delhi are not presented here as an indictment of the technical guidelines for TB control known as DOT, but to illustrate two key points:
1)  that rigid application of technical guidelines, however soundly based and well-intentioned, without reference to key aspects of social context (including capacities and priorities of health service providers), may undermine a program’s potential effectiveness; and
2)  that the control paradigm on which most public health programs are based may fail to meet the health needs of patients and their communities.  Refocusing public health around a notion of care and support should support a process whereby the needs of public health and the needs of patients are both satisfied.

Q18_Recc:
Four key lessons for TB control emerge from this discussion:
1)  We must continue to develop positive multi-disciplinary collaborations with “each other” and partnerships with communities and health workers;
2)  We need to begin to shift our thinking away from “control” and start to focus on “care”;
3)  We need flexibility and process in program and policy development;
4)  We need to learn to listen to those who know.  This includes patients and members of their communities as well as those working within the health service provision sector.


Q1_Title:
Shifting the paradigm in tuberculosis control: illustrations from India

Q1_Author:
Ogden, J., Rangan, S., Uplekar, M., Porter, J., Brugha, R., Zwi, A., & Nyheim, D.

Q2_Key:
TB; India; compliance; treatment seeking; access

Q6_ReQue:
This paper focuses on the answer to the question, ‘who is to blame for treatment failure in TB?’  It argued the need to reorient TB control programs towards enabling patients to obtain care.

Q14_Desc:
This review article critiques TB control failures based on literature from India and social science.  This paper argues for the need to reorient TB control programs away from a focus on treatment-taking and towards a commitment to enabling patients to obtain the care they need, want, and deserve.  The paper focuses on the epidemiological, economic, and social burden of TB in addition to seeking treatment and accessing health care services with discussion of people’s knowledge and beliefs of TB, access to services, and compliance.  Examples of successful NGO TB programs that use non-DOT methods are discussed.

Q15_Outc:
Neglecting the importance of the broader structural factors and instead placing particular emphasis on ‘cultural beliefs, perceptions, and knowledge’, could reinforce the current pattern of blaming patients, drawing attention away from many of the real barriers to accessing and continuing to utilize health and TB care services, which include poverty, social and economic inequality, and gender inequalities.

Q17_Conc:
Limited access to TB care is more likely a result of system failures rather than treatment failures.  Barriers to accessing and using health care and TB services should not emphasize cultural beliefs, perceptions and knowledge over the structural and health system factors that explain patient behavior.  Despite these barriers, policy makers and program managers need to recognize that patients wish to improve their health and complete treatment but are challenged by health care systems that fail to meet their needs.  Herein lies the need for a qualitative paradigm shift from the need to control patients to providing health and TB services that support communities as they strive for a cure.

Q18_Recc:
Little research has been done to understand the social burden of TB on households/families and communities, the connection between gender and TB, and the social and operational aspects of DOT programs.  International TB strategy needs to focus on health in communities rather than diseased individuals.  There is a need for more social science research, including emphasis on the roles of household support and gender effects, to inform and improve the effectiveness of TB programs and policies.  There is also a need to develop measures to improve quality of care (e.g., structural inequalities, health service inadequacies, etc.) with less emphasis placed on individuals and their behaviors and beliefs.


Q1_Title:
Detention of Persistently Nonadherent Patients with Tuberculosis

Q1_Author:
Oscherwitz, T., Tulsky, J., Roger, S., Sciortino, S., Alpers, A., Royce, S., & Lo, B.

Q2_Key:
civil detention, treatment adherence, TB

Q3b_Both:
The article views treatment adherence from a perspective most closely associated with the internal domain, but the topic of civil detention is clearly an external influence on behavior.

Q6_ReQue:
To determine which patients are sought for detention, characteristics of their detention, and resulting effects on treatment completion.

Q8_SampCom:
67 patients who were sought for detention or arrest during the study period.

Q14_Desc:
The article presents retrospective descriptive case information and treatment completion data from a record review of patients sought for civil detention or arrest by California TB controllers.  The research design includes comparisons to non-arrested/detained patients in the same counties as those sought for civil action.

Q15_Outc:
Overall, controllers sought the arrest or detention of 1.3% of adult TB patients.  Of those detained, the average length of detention was just over two weeks in duration.  In terms of treatment completion, 41 of 49 detained patients completed their TB therapy.

When comparisons were made to non-detained TB patients, those who were detained were half as likely to complete therapy in 12 months and were 4 times more likely to be lost to follow-up.

Q16_Limt:
Authors cite several scenarios in which their prediction of need for detention would become invalid.  Those listed were: if the number of cases decreases because “access to housing, mental health treatment, and substance abuse programs were enhanced,” if the total number of TB cases declines further, or if patients perceive long-term detention to be a credible threat. 

Additionally, the authors mention the fact that the data may not generalize to other states or locales and that there were some limitations in the completeness of some data attained for the study.

Q17_Conc:
“Further improvements in the care of persistently non-adherent patients may require more psychosocial services, appropriate facilities for civil detention, and detaining patients long enough to assure completion of treatment.”


Q1_Title:
Nonadherence in Tuberculosis Treatment:  Predictors and Consequences in New York City

Q1_Author:
Pablos-Mendez, A., Knirsch, C., Barr, G., Lerner, B.H., & Frieden, T.

Q2_Key:
tuberculosis, nonadherence, adherence, drug resistance, antituberculosis treatment, population predictors, injection drug use, homelessness, HIV, race, directly observed therapy (DOT)

Q3b_Both:
The authors of this article hypothesized that the causes of high nonadherence rates among their target populations were due to internal factors  (and individual’s forgetfulness, knowledge, attitudes, perceptions), as well as external factors (poverty, racism, economic inequality, disparities in care, availability and access to care).

Q6_ReQue:
Objective:  To identify and analyze the predictors and consequences of nonadherence to antituberculosis treatment.

Q13_Comm:
0.05 was the level of statistical significance (see Table 1, p.165-166).

Q14_Desc:
This article set out to identify and analyze the predictors and consequences of nonadherence to antituberculosis treatment.  The article described the findings from a retrospective study of 184 patients with tuberculosis in New York City, all newly diagnosed by culture in April of 1991. The study participants were followed through 1994.  The authors found greater rates of nonadherence among non-Hispanic blacks, injection drug users, the homeless, alcoholics, and HIV-infected patients.  Census-derived estimates of household income were lower among nonadherent patients.

Q15_Outc:
Forty-eight percent of patients in the study were nonadherent.  In multivariate analysis, however, only injection drug use and homelessness predicted nonadherence, even though 39% of patients who were neither homeless nor drug users were nonadherent.  Nonadherent patients took longer to convert to negative culture (254 versus 64 days, P<0.001), were more likely to acquire drug resistance (relative risk 5.6, 95% confidence interval 0.7 to 44.2), required longer treatment regimens (560 versus 324 days, P<0.0001), and were less likely to complete treatment (RR 0.5, 95% CI 0.4 to 0.7).

Q16_Limt:
Some of the follow-up measures (e.g., mycobacteriologic testing) were not performed routinely, but the variation in treatment implementation and adherence could not have been realized under any controlled protocol.  Nonattendance at clinic appointments is a good indirect measure of nonadherence, although urine drug testing may have identified additional nonadherent cases.  No information was available on the reasons for nonadherence (e.g., clinical improvement, medication side effects, forgetfulness, concomitant illness).  Information on specific characteristics of health providers was not available, although most patients received care in more than one setting.

Q17_Conc:
While the situation in New York City during 1991 may not be representative of other settings, this investigation makes three important points.  First, without an adequate control program, adherence to antituberculosis treatment is poor (48% default rate), even if free care is available.  Second, although nonadherence occurs more commonly among minorities, the homeless, and those with a history of substance abuse, the prediction of adherence in individual patients is quite limited.  Third, as suggested by anecdotal and ecologic observations, nonadherent patients remain infectious longer, are more likely to develop drug resistance, and take twice as long to complete therapy.  The magnitude of the problem of nonadherence in tuberculosis depends on the definition used, the patient population, and the nature of local control programs.  The best predictor of nonadherence is a previous history of nonadherence.

Q18_Recc:
Directly observed therapy (DOT) has proven effective against the resurgence of tuberculosis and the emergence of drug resistance, and is cost-effective.  In New York, control efforts since 1992 have already begun to turn the tide against the disease, with treatment completion rates of 90% and a 60% drop in multidrug-resistant isolates.  (Some have argued that DOT is either unnecessary or too great a threat to civil liberties.  Indeed, there are numerous historical examples in which excessive coercion was exercised to control tuberculosis.)


Q1_Title:
Organizational Issues in Conducting Tuberculosis Screening at a Syringe Exchange Program

Q1_Author:
Paone, D., Perlman, D., Perkins, M., Kochems, L., Saloman, N., & Des Jarlais, D.

Q2_Key:
TB, injecting drug users, syringe exchange, TB screening

Q6_ReQue:
Discusses the organizational issues related to conducting TB screenings at syringe exchange centers in NYC.

Q7_TheoBas:
Works within the overall strategy of risk reduction.

Q14_Desc:
-Article describes rationale for incorporating TB screening and LTBI treatment for IV drug users.
-Describes NYC’s evaluation of the feasibility of integrating TB screening with needle exchange programs.

Q15_Outc:
-Lower East Side Needle Exchange Program (LESNEP) has 10,000 participants.
-Focus groups with staff and participants indicated that TB was perceived as a significant problem and that support for integrating TB services was present. 
-Group identified logistics, potential impact on existing LESNEP services, and confidentiality issues as potential concerns.
-Once initiated, 93% of participants returned for skin-test follow-up readings.

Q17_Conc:
“With an appropriately designed program, active drug injectors can respond favorably and adhere to on-site TB screening, despite ongoing injection drug use.”

Q18_Recc:
TB services can and should be integrated into drug treatment and needle exchange programs where infrastructure can support such arrangements.


Q1_Title:
Factors at first diagnosis of tuberculosis associated with compliance with the Directly Observed Therapy (DOT) in the Limpopo, Province, South Africa

Q1_Author:
Peltzer, K., Onya, H., Seoka, P., Tladi, F., & Malema, R.

Q2_Key:
TB, DOT, adherence, health belief model, compliance

Q6_ReQue:
The aim of the study is to compare and contrast health beliefs, demographic and socio-economic variables, causative beliefs, knowledge, health seeking behavior and health provider-patient interaction of compliant and non-compliant TB patients.

Q14_Desc:
The study aims to investigate the predisposing, reinforcing and enabling factors, which can improve the deliver of DOT programs in three predominately rural black communities in the Limpopo Province of South Africa.  This was accomplished by comparing and contrasting health behaviors, demographic and socio-economic variables, causative beliefs, knowledge, health seeking behavior, and health provider-patient interactions of compliant and non-compliant TB patients.

Q15_Outc:
Discriminant analysis between compliant and non-compliant groups after 6 months follow-up showed that the quality of the health practitioner-patient interaction and causative beliefs were associated with compliance behavior whereas knowledge, onset of TB, sociodemographic variables, health seeking behavior, and health beliefs were not associated.

Q16_Limt:
In common with other researchers’ findings was that factors associated with compliance and non-compliance seem to differ, and in some areas no clear differences were found to different studies.

Q17_Conc:
This study has proved useful in the determination of factors that must be taken into account while designing DOT interventions, which are acceptable and feasible, and therefore likely to be effective in South Africa.  Most important of these factors are: quality of health provider – patient relationship and causative belief.  They have shown that powerlessness can be thought of as a broad risk factor for improving the delivery of the DOT program; an empowerment or control over one’s destiny, as an important strategy.

Q18_Recc:
Researchers need to measure more accurately the psychological, interpersonal, organizational, and community changes that can occur as people participate in their communities to improve individual and social health.


Q1_Title:
Cost-Effectiveness of Tuberculosis Screening and Observed Preventive Therapy for Active Drug Injectors at a Syringe-Exchange Program

Q1_Author:
Perlman, D.C., Gourevitch, M., Trinh, C., Salomon, N., Horn, L., & Des Jarlais, D.

Q1_Journal:
Journal of Urban Health: Bulletin of the New York Academy of Medicine

Q2_Key:
New York City, cost-effective, screening, directly observed preventive therapy (DOPT), drug injectors, syringe-exchange program

Q6_ReQue:
Hypothesis:  The hypothesis being tested was that costs incurred by a program of TB screening and directly observed preventive therapy at a syringe-exchange program are lower than costs of treating cases of active TB that would have occurred in the absence of the intervention.

Q8_SampCom:
974 syringe-exchange participants agreeing to TB screening

Q12_Oth:
Needle Exchange Program (Lower East Side Needle Exchange Program)

Q14_Desc:
This study examined whether costs associated with tuberculosis screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented.  The authors examined the impact of monetary incentives to promote adherence on cost-effectiveness.

Preventive treatment program costs included those of staff, supplies, rent, overhead, liver function tests, CXRs, INH, and monetary incentives for skin testing.  The authors used published data to project the incidence of TB expected to be averted by INH preventive therapy across a range of INH effectiveness.  The authors then weighed the costs incurred by conducting the intervention (screening, excluding active disease with chest radiographs, providing DOPT, and monitoring for and managing hepatotoxicity) in a hypothetical 1,000 patients (Table 2, p. 557) against the costs of managing the excess cases of TB that would have occurred in the absence of the intervention (Table 3, p. 558).  The authors calculated the cost of screening and DOPT per TB case averted and the net savings associated with the intervention.  (See page 554 for a list of the assumptions the authors used to derive cost estimates and approximate numbers of tuberculosis cases that would have arisen in the absence of DOPT over a five-year period.)

Q15_Outc:
Cost-Effectiveness as a Function of Chest X-ray Referral Adherence and Incentive Costs:  Incomplete adherence to screening CXRs reduces the pool of subjects eligible for DOPT and increases the pool of subjects who remain at risk for incident TB.  For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081.  Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost-saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings.  If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a five-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively.

Because the benefits derived by INH preventive therapy is proportional to the number of doses taken, this analysis also effectively represents, for any given intrinsic degree of INH activity, the effect of varying degrees of adherence to INH preventive therapy on cost-effectiveness. Hence, these data suggest that the intervention may remain cost saving even with variable adherence.

Q17_Conc:
The authors conclude that TB screening and DOPT at syringe exchange programs is an efficient and cost-effective strategy for reducing TB among active drug uses, generating protective benefits for the individual and diminishing future TB treatment costs.  In the authors’ analysis, the cost savings identified accrue to society as a whole, rather than to the individuals being screened or to the syringe-exchange program itself.  Based on cost, there would be little incentive for a syringe-exchange program to fund TB screening and on-site preventive therapy because the potential savings accrued would be realized not by the syringe-exchange program, but by the health care delivery systems that would otherwise have borne the costs of TB treatment.  The generalizability of the model would therefore depend on the funding and staffing available to conduct such programs.  However, important public health benefits might accrue if funding for TB screening and preventive therapy were allocated, which would create linkages between SEPs and the clinical/public health providers and agencies (e.g., Medicaid, or other insurers) that would otherwise have borne the costs of TB treatment.

Q18_Recc:
Monetary incentives have been found to be highly effective in promoting adherence to voluntary DOPT, in facilitating acceptance of and adherence to TB skin testing and SEPs, and in improving return rates for PPD interpretation.  The authors found that the use of monetary incentives for hose referred for screening CXRs would be justified on a cost basis if it had been even a modest beneficial impact on adherence.  To our knowledge, the impact of monetary incentives on TB program cost-effectiveness has not previously been evaluated.  Monetary incentives do pose significant program costs.  Consequently, acceptance of incentives as a routine part of an ongoing clinical or public health program would require that the incentive effectively promote improved adherence, and that the benefits derived from such improved adherence offset the costs of the incentive program.


Q1_Title:
Tuberculosis prophylaxis in the homeless

Q1_Author:
Pilote, L., Tulsky, J., Zopola, A., Hahn, J., Schecter, G., & Moss, A.

Q6_ReQue:
Objective:  To test two interventions aimed at improving adherence to tuberculosis evaluation and to identify predictors of adherence.

Q9_Other:
In the peer health advisor group, the peer health advisor provided an account of the TB clinic appointment.  In the monetary incentive group, the research assistant’s signed receipts were checked.

Q13_Comm:
The X2 test (or Fisher’s exact test) was used to test associations for categorical variables. Variables with P£0.10 were entered in a forward stepwise logistic regression model, along with the treatment groups.

Q14_Desc:
The authors designed a study to test two interventions aimed at improving adherence to a first follow-up appointment at a TB clinic in a homeless population.  One intervention consisted of employing peer health advisers, individuals selected from the homeless community, as community health workers.  The study hypothesized that because of their familiarity with homelessness and the ways of the street, peer health advisers could facilitate access to health care in this homeless group.  The other intervention consisted of providing a monetary incentive to motivate subjects to keep clinic appointments.

Q15_Outc:
Of the subjects assigned to a monetary incentive 69 (84%) completed their first follow-up appointment, compared with 62 subjects (75%) assigned to a peer health adviser and 42 subject (53%) assigned to usual care.  Adherence was higher in the monetary incentive and peer health adviser groups than in the usual care group (P<0.001 and P=0.004, respectively).  Patients not using intravenous drugs and patients 50 years of age or older were more likely to adhere to a first follow-up appointment (odds ratios [95% confidence intervals], 2.5 [1.3 to 5.0] and 3.3 [1.2 to 8.8], respectively).  Among the 173 tuberculosis-infected subjects who completed their appointment, isoniazid therapy was started for 72 individuals, and three cases of active tuberculosis were identified.

Q16_Limt:
One important limitation in this study is that the authors studied adherence to a first appointment in a group that had already demonstrated interest in the study.  These subjects were among those who agreed to be screened and those screened who came back to get their test results.  Additionally, they agreed to be enrolled in the present adherence study.  Therefore, this study’s findings may not be generalizable to all homeless individuals.

The authors acknowledge possible extraneous factors that may have affected their research:  
First, there was a lot of publicity about multidrug-resistant TB during the study period, especially in the shelters.  Second, involvement in the randomized trial, even in the control arm, probably had some intervention effect, as the importance of the follow-up appointment was stressed at recruitment.  Finally, subjects who consented to randomization may have been more motivated than those who did not.

Q17_Conc:
Interventions tailored to the needs of the homeless individual improve adherence to a first follow-up appointment at the TB clinic.  A monetary incentive intervention was very effective. However, the implementation of monetary incentives may present logistical difficulties, especially in public health clinics that cater to many impoverished groups.  The effect of the peer health advisers was lesser but better than usual care.  Peer health advisers may have beneficial effects on other aspects of their homeless clients’ lives that require further evaluation.  Nevertheless, money may have to be used to improve adherence in homeless groups at high risk for highly contagious infections.

Q18_Recc:
The potential benefits of the peer health adviser/client interaction should be systematically evaluated in future studies.  Peer health advisers did more than strictly getting their clients to clinic for screening.  They taught their clients about TB and HIV infections.  They also discussed issues related to housing, substance abuse, and welfare checks.


Q1_Title:
Ethics of directly observed therapy for the control of infectious diseases

Q6_ReQue:
This paper considers the difficult relationship between public health and ethics within the perspective of infectious diseases using TB as an example.

Q14_Desc:
This paper describes the ethical debate around the use of DOT for infectious disease control, using TB as an example. Four ethical principles – autonomy (“self-rule”), beneficence (medical benefit), non-maleficence (no harm), and justice (moral obligation and equality) – provide a basis for rigorous consideration and resolution of the ethical dilemma.

Q15_Outc:
The article is divided into the following sections: Ethics; Moral issues in public health interventions; Infectious disease control; and an ethical case study of TB. The TB case study discusses TB control, TB control structures, compliance and adherence, socio-economic factors, DOT, and low and high TB prevalence using an ethical perspective based on the four principles.

Q17_Conc:
Ethical debate provides an important focus for infectious disease control activity. It is important to ensure that the autonomy and freedom of individuals is not jeopardized by the government or public health profession. Moreover, infectious disease control activities developed for one country may not be appropriate for another country. Public health professionals need to highlight and debate the moral dilemmas present in infectious disease control. Finally, DOT as an appropriate health intervention or merely a means to avoid tackling the major public health issues of inequality and poverty needs to be addressed.


Q1_Title:
The way forward: An integrated approach to tuberculosis control

Q1_Pages:
359-378. Singapore: Imperial College Press

Q3b_Both:
Chapter looks at changing perceptions in public health and includes more social science evidence in addition to the disease control model

Q14_Desc:
This book chapter reviews different and integrated approaches to TB control. It discusses social dimensions of public health, collaborations across disciplines, and problems with the TB control model.

Q15_Outc:
Public health has change and professionals now need to consider the social dimensions of disease. A new approach to TB control will need to incorporate qualitative research and social science perspectives. Social dimensions in public health include: income inequality and disease burden; social capital; importance of social factors in disease transmission; health promotion and education; multidisciplinary and intersectoral collaboration; and increased international interest in ethics and human rights.
The chapter reviews TB and other infectious disease control models, which focus on the biomedical perspective, the individual, and notion of individual risk. Shortcomings of this approach are discussed and the need to include social dimensions is advocated. Finally, the history of TB control is reviewed and future directions are discussed. Specifically, a people-centered health development/research approach is advocated. This process involves interdisciplinary study within researchers, the community, and policy and decision makers.

Q17_Conc:
A new approach to TB control is one that requires a broader look at non-medical factors that determine health: social life, environment, human biology, and inequality in access to resources – globally and locally.


Q1_Title:
Factors Associated With Participation by Mexican Migrant Farmworkers in a Tuberculosis Screening Program

Q6_ReQue:
The purpose of this study was to analyze the relationship between psychosocial variables from a framework comprised of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) and participation of Mexican migrant farmworkers in a TB Screening program.  Five hypotheses on the positive relationship between variables were examined.

Q7_TheoBas:
The study used a theoretical framework based on the Health Belief Model and the Theory of Reasoned Action.

Q10_AduUSBrn:
Mexican—either born in Mexico or who had 1 parent born in Mexico

Q10_AduFrBrn:
Mexican—either born in Mexico or who had 1 parent born in Mexico

Q13_Comm:
Pearson correlations supported the hypothesized associations between the variables from the combined HBM & TRA model and participation in the screening program.

Q14_Desc:
A convenience sample of 206 Mexican migrant farmworkers were recruited after a presentation of a TB education program and were tracked during the administration and reading of the TB skin test. The study was carried out in conjunction with a TB education & screening program in northwestern New York at 20 migrant farm camps.

Q15_Outc:
Most subjects were male, aged 18-27 years, and had less than a sixth-grade education. Of the 206 participants, 152 (73%) received a skin test and 149 (98%) returned to have their test read, of which 44(29.5%) tested positive.  The model that best predicted intention to participate in TB screening included cues to action, subjective norm, susceptibility, and attitude.  Participation in screening was best predicted by a model containing only 2 variables:  intention and susceptibility. All 5 research hypotheses were supported.

Q16_Limt:
Based on the model used, it is not possible to posit a causal relationship between attending the education program and participation. The results of this study can not be generalized to settings where migrant farmworkers must travel to obtain healthcare services.

Q17_Conc:
Logistic regression analyses showed that the more parsimonious model than the full combined HBM & TRA model predicted both intention and behavior. The high rate of participation suggests that migrant farmworkers will participate in screening when given the opportunity to be tested in a culturally appropriate & geographically accessible program.

Q18_Recc:
The findings suggest several lines of future inquiry: the research instrument developed for this study (TII) could be tested with migrant farmworkers in other settings or modified to study migrant workers’ behaviors related to other types of disease screening.  The combined HBM & TRA model could be applied to study postscreening behaviors such as having a chest radiograph, and initiating and following through with isoniazid prophylaxis. Nurses who offer educational programs to migrant farmworkers may wish to incorporate some of the study results in designing such programs.


Q1_Title:
Developing an Instrument to Study the Tuberculosis Screening Behaviors of Mexican Migrant Farmworkers

Q2_Key:
TB, TB screening, migrant farmworkers, Health Belief Model (HBM), Theory of Reasoned Action (TRA)

Q6_ReQue:
The article details the development and evaluation of an instrument using aspects of the HBM and TRA to understand the TB-related health behaviors of migrant farmworkers.  Also describes the development of the Tuberculosis Interview Instrument (TII).

Q7_TheoBas:
The instrument is based on components of the HBM and TRA.

Q8_SampCom:
Sample size (N)= 26 participants in the Qualitative Study, 20 in the Pilot Test of the TII, and 206 in a subsequent Quantitative Study using the instrument.

Q11_USA:
US (states not specified):  various locations depending on phase of study

Q14_Desc:
The article describes three components of the development and use of the TII.

Qualitative Study:  Initial qualitative information was derived from a prior study with migrant workers published (and abstracted as part of this literature review) as Poss, 1998.  The results of this study were combined with quantitative items based on HBM and TRA theory to create the initial version of the TII.

Pilot Study of the TII:  The pilot study was completed by interviewing 20 migrant farmworkers with the newly developed instrument to ascertain clarity, content, ease of administration, and reliability.
Subsections were examined for internal consistency with Chronbach’s alpha and slight modifications were made to the instrument.

Quantitative Study:  Following modifications to the TII, a quantitative study was completed with 206 participants being interviews with the instrument.  Results of this study are reported elsewhere.  Further modifications were made to the TII based on these results.

Q15_Outc:
The final tested version of the instrument had Chronbach’s alpha scores for the subscales ranging from 0.71 to 0.96 and was deemed appropriate for future use and testing.

Q17_Conc:
TII is a valid reliable instrument for use with migrant farmworkers in the New York State.  It is in need of further testing and norming on other populations.

Q18_Recc:
Further testing of the instrument is recommended among farmworkers in other areas of the United States, and should be administered to large samples so as to facilitate factor analysis to guide further use.


Q1_Title:
The Meanings of Tuberculosis for Mexican Migrant Farmworkers in the United States

Q2_Key:
explanatory models, migrant farmworkers, TB

Q6_ReQue:
To investigate explanatory models of TB among Mexican migrant farmworkers

Q7_TheoBas:
Grounded Theory method was used for analysis.

Q8_SampCom:
Sample size (N)=   26 (21 male, 5 female; average age of 27 (males) and 36 (females) years.  25 fluent in Spanish, one asked to be interviewed in English.

Q14_Desc:
Participants were recruited from 10 different migrant camps.  No compensation was offered to participants.  Interviews were performed in the evenings in the respondent’s preferred language using a structured, open-ended interview schedule consisting of 19 different items.  The questions addressed beliefs, knowledge, and feelings related to TB.

Q15_Outc:
-Many new TB was caused by an organism, but did not know specifics.
-Most knew transmission occurs through airborne means.
-About two-thirds had some education regarding TB (from outreach education interventions).
-Most recognized the seriousness of TB and correctly assessed their susceptibility.
-Some confusion exists about how skin tests should be interpreted and what the implications of vaccination were for other diseases.
-Two-thirds agreed that they would seek treatment from a MD if they were diagnosed.
-Varying opinions on the social significance of TB.

Q16_Limt:
The results may not be representative of all migrant workers since many in this particular sample had experienced some form of TB outreach education.

Q17_Conc:
1. Farmworkers may posses a basic level of TB knowledge
2. Many had misconceptions about BCG vaccine (felt it protected against disease like measles, etc.)
3. Opinions vary regarding social stigma.

Q18_Recc:
Additional research must look at macro-level factors such as poverty, traveling long distances to work, overcrowded living and working conditions, etc. to understand contributions to disease.


Q1_Title:
A Tuberculosis Screening and Treatment Program for Migrant Farmworker Families

Q1_Journal:
Journal of Health Care for the Poor and Underserved

Q2_Key:
TB, screening, migrant, farmworkers, PPD skin test

Q6_ReQue:
To objective was to provide TB screening and treatment for migrant farmworkers and their families.

Q10_AduFrBrn:
Hispanic, Black (although not specifically stated)

Q10_ACIFrBrn:
Hispanic, Black (although not specifically stated)

Q14_Desc:
This paper describes the results of a community health outreach program conducted during (June and August) 1994 and 1995 migrant seasons to provide TB screening and treatment for migrant farmworkers and their families in Monroe and Orleans Counties in northwest New York State.

Q15_Outc:
A total of 853 migrant farmworkers attended education programs and were screened for TB in 1994 and 1995.  Of those screened 843 (99%) were located for skin test readings.   197 (23%) had positive skin tests.  Screening programs were conducted in the site day care centers and at migrant education summer school programs.  In these sites, 472 persons under 21 years of age, and 53 showed positive PPD skin tests.  For farmworkers aged 21 – 40, the rate of positive readings was 39.6%, and for those over age 40, the rate was 36%.

Q17_Conc:
The number of persons completing therapy was higher when health department personnel were actively involved throughout both the screening and follow up phases.  A high percentage of compliance is due to the diligence of the health promoters in locating farmworkers to read their skin tests and the good rapport between the two groups.  The methods used in this program, which included culturally sensitive education, bilingual/bicultural health promoters, cooperation of the county health department, and intensive follow-up, may be applicable for other health centers in providing TB screening and treatment programs for migrant farmworkers.


Q1_Title:
Approaches to improving adherence to antituberculosis therapy-South Carolina and New York, 1986-1991

Q1_Author:
Pozsik, C., Kinney, J., Breeden, D., Niven, B., & Davis, T.

Q2_Key:
patient, adherence, TB, South Carolina, New York City, DOT

Q6_ReQue:
This report describes the experiences of selected strategies in South Carolina and New York City and provides recommendations for improving patient adherence to anti-TB therapy.

Q8_SampCom:
1,554    1,521 SC patients non-adherent to TB therapy + 33 NY in-patient commitments

Q11_USA:
South Carolina and New York:  New York City, NY

Q13_Comm:
Findings with statistical significance were included for NYC.

Q14_Desc:
During 1986-1991, the South Carolina Department of Health and Environmental Control and the New York City Department of Health (NYCDH) attempted to improve patient adherence to anti-TB therapy by employing a combination of strategies that included incentives, directly observed therapy (DOT) (i.e., health-care worker observation of the patient ingesting each dose of medication), court-ordered DOT, and commitment for inpatient management.

Q15_Outc:
From 1986 through 1991, by using a combination of these strategies, South Carolina increased the overall completion of anti-TB therapy from 93.9% to 96.5% and decreased the number of new TB cases from 593 in 1986 to 410 in 1991. In New York City, patients were more likely to have a successful outcome if the length of commitment for inpatient management was more than 62 days (eight {62%} of 13 patients versus two {10%} of 20 with less than 62 days {relative risk (RR)=6.2; 95% confidence interval (CI)=1.5-24.5}) and if patients were domiciled (eight {50%} of 16 versus two {12%} of 17 homeless {RR=4.3; 95% CI=1.1-17.1}).

Q17_Conc:
The experience in South Carolina indicates that most patients who are chronically nonadherent can be cost-effectively treated using a variety of approaches other than commitment for inpatient management (Pozsik, 1989).  The findings from New York City indicate that even an approach as intense as commitment does not ensure that patients will be cured. Those findings also suggest that commitment for periods less than the full course of therapy may be ineffective.

Q18_Recc:
To increase completion of anti-TB therapy, local and state health departments are encouraged to 1) employ the full range of TB-therapy strategies according to individual patient needs; 2) provide accessible clinical TB services and anti-TB medications at no cost to patients; 3) monitor adherence among patients; and 4) develop working relations with other agencies that provide social services, treatment for drug and alcohol abuse, and residential facilities for patients who need them (Pozsik, 1989, ATS/CDC, 1992).  CDC and ATS recommend that consideration be given to treating all TB patients with DOT (ATS/CDC, 1992).


Q1_Title:
Awareness About Tuberculosis Among General Population:  A Pilot Study

Q1_Author:
Purohit, S., Gupta, M., Madan, A., Gupta, P., Mathur, B., & Sharma, T.

Q2_Key:
India, knowledge, diagnosis, treatment, illiterate, socio-economic status, rural

Q6_ReQue:
Objective:  The present pilot study was undertaken to assess the extent of knowledge of the common masses about tuberculosis.

Q14_Desc:
The authors of this study compiled a survey to determine the extent of knowledge about tuberculosis within India’s general population.  (No particular region or area was given.)  The authors divided their survey into three parts:  Set A (related to general aspects of tuberculosis), Set B (related to diagnosis and treatment facilities), and Set C (related to preventive aspects of tuberculosis).  One thousand people from different walks of life (businessmen, clerks, slum-dwellers, students, teachers, etc.) were interrogated with a descriptive questionnaire between January and June 1986.  Subjects completed the survey by themselves; illiterate persons were read the survey aloud and had their answers recorded.
Responses to each set of the survey were taken as correct when 50% or more of the answers in each set were correct.

Q15_Outc:
Among the 650 subjects of low socioeconomic status, 49.5% answered Set A’s questions correctly on the general aspects of TB.  In the same group, questions related to Set B (diagnosis and treatment facilities) and Set C (preventive aspects of TB) were correctly answered by 67% and 48.6% of subjects, respectively.  Of the 350 persons of high socioeconomic status, 88.6%, 82.8%, and 87.1% gave correct answers to sets A, B, and C, respectively.

Nearly 85 to 92 percent of the study’s 140 illiterate persons were either unaware or had wrong conceptions about tuberculosis, whereas this phenomenon was witnessed in 18 to 29 percent of the literate group (860 subjects).

Out of 380 persons belonging to the rural group, 36.8%, 45%, and 28% correctly answered sets A, B, and C, respectively.  Among the urban cohort of 620 persons, 83.5%, 89.5%, and 18.5% correctly answered questions to sets A, B, and C, respectively.

Q17_Conc:
If the results of our study are extrapolated to a district population it reflects the simple fact that nearly 80% of the population is not aware of the preventive measures to be taken for tuberculosis and nearly one–fourth of the population is unaware of the facilities for diagnosis and treatment of tuberculosis.  Hence, there is an obvious need for training courses for PHC staff, refresher courses for doctors and education of the community at large. 

What is required at this stage is a systematic, simple, and regular program for educating the public about tuberculosis.  It sounds logical to introduce chapters on tuberculosis in textbooks for primary and middle standard medical students, reinforced continuously by mass media.

Q18_Recc:
It is claimed that in recent years, knowledge about tuberculosis has improved but probably, has not percolated down to patients.  This could be due to a lack of communication between patients and doctors, either because of heavy workloads at health centers or because of a lack of interest on the part of the doctors.  Technical and organizational methodology to reduce this gap can go a long way towards making the public aware of tuberculosis and reducing the pool of infection by better case-finding and case-holding.  Mass media (TV, radio, newspapers, cinema slides, hoardings at public places) have been tried, with some success.


Q1_Title:
Family Tuberculosis Contacts: Resource-Contingent Management

Q2_Key:
Family practice, BCG vaccination, family physician, family relationship

Q6_ReQue:
Because of the renewed emphasis on drug treatment in tuberculosis control, family physicians and the health personnel they supervise need to be involved in this effort.

Q14_Desc:
Recent findings in tuberculosis research have questioned the efficacy of the BCG vaccination and demonstrated the effectiveness of combined-drug chemotherapy and isoniazid chemoprophylaxis, both in regimens of under 12 months duration.  Despite differences in health care resources in different regions, rational and effective management of active cases and their contacts in the family can be devised.  While the priority remains treatment of the active index case, family physicians have a unique opportunity to use family relationships to find and to treat other active cases, and to reinforce compliance with INH chemoprophylaxis by high-risk family contacts.

Q17_Conc:
In areas where chemotherapy of smear-positive tuberculosis cases is well established, the next step is the investigation of family contacts. This should be followed not only be combined-drug treatment of additional cases discovered, but also by concurrent INH prophylaxis for close family contacts.  For family physicians this is an epidemiologically complementary, socially appropriate and inexpensive next step in the control of tuberculosis in their communities.

Q18_Recc:
Prophylaxis with INH is rarely employed outside North America, owing to the difficulties of ensuring coverage and long-term compliance in vertically organized public TB programs, coupled with a traditional reliance on the BCG vaccine.  To renew the consideration of INH prophylaxis for family contacts, the author suggests the following approaches:

1) Establishing a Priority of Contacts:  Among the pulmonary cases, those patients who are positive on direct sputum smear are far more infectious than those who are smear negative.  Unless resources are relatively abundant, the latter rarely merit contact investigation.   Ordinary extrapulmonary index cases are of low priority unless they are proven to be TB by biopsy or bacteriology and are young children, where the source case is likely to be easily found in the current family household.
2) Management of Contacts:  (see Figure 1, page 32)
3) Role of the Family Physicians:  Vaccination with BCG is not applicable in family tuberculosis outbreaks, since most of the potential transmission of tuberculosis infection has occurred by the time the index case is discovered.  Compliance in drug regimens should be enhanced if the family is managed as a unit by a family physician (or primary health care worker) who has an ongoing clinical relationship with the entire family.  Ideally, a skillful family physician will extend his or her therapeutic alliance with the family so that family members themselves reinforce each other’s drug compliance.
4) Applicability of Chemoprophylaxis with Isoniazid:  Preventive treatment with INH should be restricted to contacts aged under 35 years, especially because in most developing nations, half the population will have been infected by the age of 35, possibly years before the current family investigation.  Since half the lifetime risk of active disease occurs in the two years following initial infection with tuberculosis, those infected in the remote past are at low annual risk for activation, even when exposed to a new source case in the family, because they are relatively resistant to re-infection.  Another reason to withhold prophylaxis for contacts over 35 years of age is the potential for liver toxicity from INH.


Q1_Title:
Socio-economic impact of tuberculosis on patients and family in India

Q1_Author:
Rajeswari, R., Balasubramanian, R., Muniyandi, M., Geetharamani, S., Thresa, X., & Venkatesan, P.

Q2_Key:
economic impact, cost identification, women, children, socio-economic, India

Q6_ReQue:
Objective:  To quantify the socio-economic impact of tuberculosis on patients and their families from the costs incurred by patients in rural and urban areas.

Q11_Intl:
India:  Chennai City, Kancheepuram, and Thiruvellore, in Tamil Nadu State, South India

Q14_Desc:
The purpose of the present study was to document the socio-economic impact of tuberculosis in both men and women.  An interview schedule prepared from 17 focus group discussions was used to collect socio-economic demographic characteristics, employment, income particulars, expenditure on illness, and effects on children from newly detected sputum-positive pulmonary tuberculosis patients.  The direct and indirect costs included money spent on diagnosis, drugs, investigations, travel, and loss of wages.  Total costs were projected for the entire 6 months of treatment.  

In order to obtain a representative sample from the rural and urban populations, the present study was conducted among patients attending government and NGO hospitals and clinics situated in Chennai City and two rural districts.  In addition, patients receiving treatment from private practitioners (PVT) in Chennai City were also interviewed.

Q15_Outc:
The study population consisted of 304 patients (government health care 202, non-governmental organizations 77, and private practitioners 25), 120 of whom were females.  Mean direct cost was Rs.2052/-, indirect Rs.3934/-, and total cost was Rs.5986/- ($171 US).  The mean number of workdays lost was 83 and mean debts totaled Rs.2079/-.  Both rural and urban female patients faced rejection by their families (15%).  Eleven percent of school children discontinued their studies; an additional 8% took up employment to support their family.

Direct costs were lowest among patients attending GH facilities, and were 6.5 times higher among patients attending PVT facilities.  The overall indirect cost was more than the direct cost for employed patients, as patients lost wages for a period of 40-60 days (16% of annual working days).  The present study showed that expenditure due to tuberculosis accounted for as much as 40% of patients’ mean annual income, while indirect costs alone were responsible for 26% of annual income.

Women in India face special constraints, and are often dependent on others for obtaining necessary medical attention.  In this series the total direct cost incurred by women was higher than that for men (Rs.2287/- vs. Rs.1899/-).

Q17_Conc:
The mean total cost observed per patient in this study was Rs.5986/-.  This alarming figure should furthermore be interpreted as an underestimate, as indirect costs for unemployed persons have not been analyzed and included in this estimation.  A comparison of the total costs estimated in earlier studies in India with those of the present study reveals a worrying increase over a period of 30 years.

In recent times, economic issues have had a growing importance in the health care field.  This study has clearly documented the socio-economic and personal suffering of tuberculosis patients and the resultant huge costs in personal and health budgets.  The results of this study may be used to develop new approaches for policy-makers, potential donors, and health service personnel towards more effective promotion of tuberculosis control.

Q18_Recc:
Sixty-seven percent of rural patients and 75% of urban patients incurred tuberculosis-related debts in the present series.  This study has shown the need to provide adequate financial support to tuberculosis patients from the poorer sections of the community, since they are thrown even further into poverty as a result of the disease.  Free supplies of anti-tuberculosis drugs alone may not be sufficient to improve the compliance of tuberculosis patients.

Also, tuberculosis control in women is an investment in the future health of women themselves, their children, and society at large.  The results of this study emphasize the need for encouragement to organize special support groups in the community for TB patients, especially for women, who are threatened by the prospect of rejection by the family/community.


Q1_Title:
Tuberculosis Awareness Among Educated Public In Two Cities in Tamilnadu

Q1_Author:
Ramachandran, R., Diwakara, A., Ganapathy, S., Sudarsanam, N., Rajaram, K., & Prabhakar, R.

Q6_ReQue:
This study aimed to measure the level of awareness among literates in two urban communities of the facts regarding TB and its management.

Q10_AduOth:
Educated population (high school and above)  - Bank employees, clerical staff at Accountant General’s office, TV Center, Social Welfare Board office

Q11_Intl:
India: Tamilnadu: Madras and Madurai City

Q12_Oth:
Other public institutions: Banks, TV station, and government offices

Q13_Comm:
Descriptive and categorical data – no tests of significance

Q14_Desc:
A questionnaire on source of information regarding TB, signs and symptoms, diagnostic methods, treatment duration and personal and community hygiene relating to TB, was administered to 446 students and employees with an education status of high school certificate and above.

Q15_Outc:
The main source of information was books and magazines, and 86% were aware that the TB germ was the causative agent. Symptoms of TB such as cough (85%) and loss of weight (74%) were well known. Other symptoms such as chest pain (29%), fever (27%) were less know. Sputum examination as a diagnostic tool was known to 68% while 80% knew about radiograph being used to diagnose the disease. Cough as a method of spread was known to 91. In this questionnaire the duration of treatment was the least know fact – 28% felt that treatment could be stopped if symptoms disappeared. Sixteen percent were aware that the method of sputum disposal was by incineration.

Q16_Limt:
Convenience sample – available on day of the interview.

Q17_Conc:
This educated sample population was found to be aware of the cause and symptoms of TB and also about diagnostic tools. But they were not aware of duration of treatment and sputum disposal.

Q18_Recc:
There are areas where more efforts need to be made in TB health education. It is recommended that intensive education regarding treatment and treatment-adherence is explored.


Q1_Title:
Tuberculosis in physicians: compliance with surveillance and treatment

Q1_Author:
Ramphal-Naley, L., Kirkhorn, S., Lohman, W., & Zelterman, D.

Q6_ReQue:
The purpose of this study was to determine the prevalence of positive skin test results and to measure compliance with Tb surveillance among physicians at SPRMC.  The hospital's surveillance protocols have changed as a result of the guidelines issued by the CDC in 1994, and physicians are now required to comply with annual skin testing.

Q10_AduUSBrn:
groups not stated; "minorities" mentioned

Q10_AduFrBrn:
groups not stated; "minorities" mentioned

Q14_Desc:
A two page self reporting questionnaire was sent August 15, 1994, to the 325 physicians at St. Paul Ramsey Medical Center (SPRMC).  189 Full time staff, 30 associate (part-time) physicians, and 65 resident physicians in training were all included in the study.  The physicians responded to the questionnaire that asked about demographic and professional characteristics, current status of tuberculin skin test results, and follow-up of physicians with positive skin test results.   Physicians were informed that failure to respond voluntarily to the questionnaire would prompt follow-up telephone interviews.

Q15_Outc:
The study found that 71% of resident and full time physicians were current in their tuberculin skin test results, whereas 66% of associate physicians were up to date.  13% of the resident and full-time physicians had positive Tb skin test results, compared with 20% of associate physicians.  Female physicians had a lower prevalence of positive skin test results than did male physicians.  The departments of pathology, surgery, and pediatrics had the highest prevalence of positive skin test results, followed by radiology, emergency medicine, and obstetrics and gynecology.  Family practice and internal medicine were among the departments with the lowest prevalence of positive skin test results.  Physicians obtained their skin tests from multiple sources and had their test results interpreted in multiple facilities; hence the test procedure was not uniform.  Compliance with disease prophylaxis was 55% among resident physicians with positive Mantoux test results, 44% among the full-time staff physicians, and only 17% among the associate physicians.  More than half of the physicians with positive Mantoux test results remained untreated.

Q16_Limt:
The Mantoux skin test procedure, both application and test interpretation, needs to be standardized.  There was wide variability in skin testing procedure among physicians at SPRMC.  Physicians undergo skin testing and have them read by a variety of sources.  This makes verification of compliance with testing and tracking of results difficult and interferes with follow-up of positive test results.  Different criteria may be used in interpreting test results, and some physicians with positive skin test results may go undetected.  The variation in source of testing seems to be a result of physicians seeking convenient access.  Hospitals will need to improve accessibility and availability of testing to institute uniform surveillance for all health care workers, including physicians.

Q17_Conc:
In summary, physicians are at a greater risk than the general population for acquiring TB and have 2 to 10 times greater prevalence of positive tuberculin skin test results than the general population.  This study shows that there are significant differences in the three subgroups of physicians studied; the full-time staff and resident physicians are somewhat more compliant than the associate staff physicians.  Understanding these differences enables hospitals to target specific subgroups of physicians that need to improve compliance.  Physicians’ voluntary compliance with tuberculin skin testing has improved slightly since previous studies but is still below desirable levels.  Hospital enforcement is essential if surveillance is to be complete, efficient, and effective in monitoring excess morbidity among health care workers.


Q1_Title:
Socio-cultural dimensions in tuberculosis control

Q1_Pages:
265-281.  Singapore: Imperial College Press

Q2_Key:
TB, socio-cultural, beliefs, health seeking behavior

Q3b_Both:
The article discusses both internal and external stressors on health by looking at people’s knowledge and the influence of socio-cultural beliefs on TB control.

Q6_ReQue:
This paper looks at people’s understanding regarding TB, their treatment seeking practices and the extent of the influence of their socio-cultural beliefs and practices on TB control.

Q14_Desc:
There are many socio-cultural dimensions in TB control in India.  This article utilizes examples to discuss several of these dimensions, causation and transmission beliefs; symptom awareness and help seeking behavior; stigma associated with TB; relationship between beliefs and treatment adherence; and cultural dimensions of provider behavior, to better understand why control and treatment are failing and how to implement more effective programs.

Q15_Outc:
A look at peoples’ perceptions regarding the pre-disposing factors and causes of TB reveal the extent to which modern scientific facts are reflected by their causation beliefs.  Level of worry because of symptoms suggestive of TB prompt suffers to seek help from health providers was very high.  The social stigma associated with TB plays a major role in all of its stages.  A closer look at the complex of problems leading to the social stigma associate with TB points out the various socio-economic and structural factors which play a major role in the perpetuation of this stigma.  It is essential for programs to be less rigid so that local health functionaries can be sensitive to practical realities and to the ‘problems of day-to-day living’ that patients face and make appropriates modifications to help the patients to complete their treatment.  Insensitive behavior of providers directly influence patients’ help seeking behavior during treatment.

Q17_Conc:
Disease control agencies must be careful not to implement global intervention policies without making the necessary local changes.  What could work and is necessary in global direction on how to procure drugs and to ensure that they reach the health centers but local policy is needed on the most effective means to get the drugs to the patients based on the socio-cultural milieu of the community.  Such a policy can be determined by local authorities who are ‘culturally close’ to the people.


Q1_Title:
Reducing the spread of tuberculosis in the homeless population

Q3b_Both:
The reviews included in this article focus on incentives for patient adherence, DOT, the interface among health care providers, hospital, and community, and also TB management.

Q6_ReQue:
The review aims to appraise current knowledge by comparing and contrasting the significance of research findings to discover if the present strategies for reducing the spread of TB within the homeless population are effective.

Q14_Desc:
The article describes literature that focuses on the partial success of interventions in the UK and USA to control the spread of TB.  The review also includes the introduction of inducements to encourage participation in screening programs and the recommendation of directly observed therapy.  Eleven papers were reviewed, with 10 of the 11 demonstrating quantitative methods for data collection.

Q15_Outc:
Findings from the literature review fall under four categories: 1) The interface between healthcare providers, hospital, and community; 2) The value of incentives in successful treatment and screening programs; 3) Directly observed therapy as a method of treating and controlling TB; 4) Comparison of TB management in the USA with that of the UK.

More specific findings include:
-The studies carried out in the USA conclude that shelters for the homeless increase the transmission of TB; the dilemma in this instance is that many healthcare providers in both countries believe that the needs of the homeless people are best served by accommodating them in shelters and hostels.
-The studies identify that homeless people often fail to obtain appropriate health care and this appears to be partially due to social exclusion.
-In the USA, homeless people are taking less responsibility for their health whereas professionals working for local healthcare providers are taking greater control of events.
-In the UK, individuals are being empowered and encouraged to make informed choices about their own health care.
-Screening of homeless people for TB is available in some parts of inner London; however, the transient nature of this population means that follow-up care may be problematic and many will be lost within the healthcare system.  This, in turn, may lead to an increase of TB within the larger population.

Q17_Conc:
TB is more prevalent in homeless people than in the general population and according to some writers the incidence may be higher than the evidence suggests.

Q18_Recc:
There is a need to improve efficiency and cooperation in passing information between healthcare providers to prevent homeless patients from being lost to follow-up treatment within the system.  Health care professionals must find ways to empower homeless persons to take more responsibility for personal health care.  Finally, nursing needs to look at new initiatives, such as other research pathways, to make a difference in the management of TB within the homeless population.


Q1_Title:
Poor, Ill, and Sometimes Abandoned: Tubercular Children in Buenos Aires, 1880-1920

Q2_Key:
TB, Buenos Aires, poverty, illness, children

Q6_ReQue:
This article examines the plight of poor children, particular tubercular ones, in Buenos Aires from 1880 to 1920.

Q14_Desc:
This article examines the plight of children, particular tubercular ones, in Buenos Aires from 1880 to 1920 and shows how public health policies and popular ideas shifted in Argentina as they did worldwide from ignoring children who were thought to rarely have TB to assisting children who came to be viewed as potential victims who needed protection from tubercular adults.  Focusing on how poverty proved a factor in their susceptibility to disease, their abandonment, and their treatment.

Q15_Outc:
Changes in attitudes toward children were reflected in increased government and charity support for new institutions and expanded programs for sick and tubercular children that involved both social action and control.

Q17_Conc:
Although government health programs and private charities in Buenos Aires remained limited and facilities were overcrowded, health professionals sought to expand programs in response to growing demands and an awareness of European efforts.  The new programs for tubercular children only partly aided poor families, including single parents, who were overwhelmed by the physical, psychological and material cost of providing for a sick or tubercular child.  Although poor parents continued to abandon sick children, tubercular children in various orphanages received the benefit of improved medical care.


Q1_Title:
Default in the outpatient treatment of tuberculosis in two hospitals in Northern India

Q1_Journal:
Journal of Epidemiology and Community Health

Q6_ReQue:
Objective:  The purpose of the study was to examine default rates in tuberculosis treatment in two hospitals in north India with different follow-up arrangements.

Q8_SampCom:
321 patients at the tuberculosis center; 381 patients at the mission hospital

Q13_Comm:
Default rates by time from first treatment were calculated by the product-limit method, and differences between default rate curves for different groups of subjects assessed by the Mantel or log-rank test.

Q14_Desc:
The purpose of the present study was to examine default rates in patients starting tuberculosis treatment in a one-year period in Northern India.  The study arose from the opportunity to compare two hospitals providing different types of tuberculosis treatment, and between them providing the only medical services for the Kulu Valley area of Himachal Pradesh.  

All patients starting treatment for newly diagnosed tuberculosis between October 1, 1982 and September 30, 1983 at either hospital were identified, and the last known status of all patients up to October 1984 was recorded.

The first facility studied, the District Tuberculosis Center, was supported by five primary health care centers, and tuberculosis patients were either self-referred or identified by the team of health workers.  Patients who missed an appointment were sent a reminder letter after three days, and were visited at home by a health worker after eight days.  The second facility, a private mission hospital, charged for all drugs and treatment and inpatient care, with exceptions made for the poorest patients, and had no well-established community health worker network.  Defaulter action was less intensive; patients who missed appointments were sent postcards after a week, with no further action taken.

Q15_Outc:
The proportion of patients who had defaulted from treatment—that is, who were at least one month late for an appointment and had not reappeared for treatment—was similar in the two hospitals, and was very high:  around 40% after six months’ treatment, 60% after one year’s treatment, and 65% by the targeted 18 months’ treatment.  The comparison of default rates is complicated by difficulties in the record system at the voluntary hospital, where a high proportion of patients were not entered in the patient registry at the time of their first visit.

Default rates increased strongly with age in the District Tuberculosis Center, and only slightly in the voluntary hospital; the higher rate in males was seen primarily in the voluntary hospital.  The highest default rate was in the low caste patients in the District Tuberculosis Center, and in the medium caste patients in the voluntary hospital.  In neither hospital did the default rate vary with the type of tuberculosis, the drug regimen used, or whether there had been a period of inpatient treatment.  However, in both hospitals, patients who had had a period of default that had been corrected (temporary defaulters) had a much lower frequency of final default.

Q17_Conc:
The similarity of the results between the two hospitals might have been because of a balancing of the different characteristics.  The voluntary hospital catered to patients who had actively chosen it despite the cost, and who had for the most part traveled a considerable distance; the patients treated were more affluent.  In the District Tuberculosis Center, the patients seen were less affluent and did not make a financial commitment, but action on first default was stronger and the hospital had the support of a network of community health workers.

Default was a major problem irrespective of the follow-up procedures employed.  The authors made recommendations concerning treatment and follow-up, including better communication about the disease and its treatment, active follow-up of defaulters, and review of treatment policies.

Q18_Recc:
The results of this study were discussed with staff at both of the participating hospitals, and the following recommendations were made regarding the treatment of outpatients with tuberculosis:

(1) Clear information on the disease, the drug therapy, and the importance of long-term drug therapy should be given to patients, both in oral and written form.
(2) High priority should be given to an active policy for the follow-up of temporary defaulters.
(3) Treatment policies should be assessed to see if treatment could be shortened, simplified, or used more selectively.  Consideration of the use of intermittent chemotherapy for patients living fairly near to centers should be considered.
(4) Initial registration of tuberculosis patients should be linked to the first prescription of drugs, perhaps by a pharmacist rather than the physician responsible for the initial registration of patients.


Q1_Title:
Tuberculosis elimination - what's to stop us?

Q6_ReQue:
Article is from a plenary lecture given during the Conference on Global Lung Health and 1996 Annual Meeting of the International Union Against TB and Lung Disease. The author cites statistics and modern day policies that have led to a lack of compliance on several levels.

Q14_Desc:
It is recognized that tuberculosis (TB) is the largest cause of death from a single infection worldwide; it infects fully one-third of the world's population, is fully 100% curable and 100% preventable and yet is nowhere near being eliminated in any area of the globe, including the most developed nations. 
The author cites statistics and modern day policies that have led to a lack of compliance on several levels.

Q15_Outc:
The failure to eliminate TB must rank as one of mankind's most serious ongoing blunders. After all, we know the pathogenesis, we know the transmission, we know how to diagnose, treat and prevent almost all cases, yet TB killed more individuals in 1996 than it did when Robert Koch discovered the bacillus that causes TB more than a century ago. TB is different from almost any other disease in that cases of TB must be actively sought and treated to keep them from spreading to others. In most diseases the untreated case dies and harms nobody. In TB the untreated or improperly treated case becomes resistant and spreads drug-resistant TB until it is found and properly treated.

Q17_Conc:
Physicians love to blame patients for noncompliance in taking drugs. However, the failure to deal with TB clearly and with documentation is due to a lack of compliance on several levels. TB will never be eliminated until this lack of compliance on all levels is addressed and corrected.


Q1_Title:
Experiments to increase return in a medical screening drive: two futile attempts to apply theory to practice

Q2_Key:
Tuberculin Skin Test (TST), return compliance, psychosocial interventions.

Q3b_Both:
Examined manipulations based on message, route, (expert or non-expert) and type (reminder card, reminder call, personal contact, etc.) of reminder messages to return for TST reading.

Q6_ReQue:
What is the success of interventions based on psychological principles designed to bolster TST return rates?

Q7_TheoBas:
Based in psychological literature surrounding message characteristics and resulting influence.

Q8_SampCom:
Sample size (N)=   200 in experiment 1, 553 in experiment 2.  Although open to all, participants were predominantly college students.

Q12_Oth:
Clinics - specifically, “TB detection drives” based at a college health clinic

Q13_Comm:
One minor variable was found to be significant in each experiment.  Overall, little support for overall research hypotheses.

Q14_Desc:
Describes two experiments to manipulate reminder prompts and participants’ commitment to TST return visits.  Used observed return for TST follow-up as sole DV.

Experiment 1 (2x4 design) examined expert vs. non-expert messages in conditions using one of: take home reminder cards, postcard reminder, phone call, or personal contacts with reminder messages.  

Experiment 2 (2x2x3 design) examined effects of enhanced message (instructions and an importance statement) versus standard reminder message (instructions only), card versus no card, and three levels of participant-expressed commitment (verbal, verbal and written, none)

Q15_Outc:
Exp. 1:  Personal reminders significantly increased return rates compared to others, no effect for expert status, and no interaction effect was found.

Exp. 2: No significant results in any relationship between variables.

Q16_Limt:
Participants were predominantly college students, so generalizability is limited.

Q17_Conc:
Failure to reject the null hypothesis was not related to procedural failure, as pre-testing and manipulation checks indicated proper adherence to research protocol.  Thus researchers concluded that no effect for the variables was seen on TST return behavior.


Q1_Title:
A tuberculosis hotline in Tyler: a Texas resource for primary health care providers for the control of infectious diseases

Q1_Author:
Robison, V., Griffith, D., Cegielski, J., Reed, M., & Nash, D.

Q2_Key:
Tuberculosis, clinical guidance, medical support, telephone hotline, usage report, Texas

Q3a_Other:
Availability of clinical information to medical providers

Q6_ReQue:
The article is a descriptive summary of the process evaluation data for a TB clinical information hotline.  The major issues summarized include: “How many calls were received by the hotline?,” “Where did the calls come from?,” “Who made the calls?” and “What were the calls about?”

Q8_SampCom:
Includes information on the 3447 calls received between Jan 1994 and Dec. 1996

Q14_Desc:
The article details the characteristics of calls logged by the statewide TB hotline in Tyler, Texas

Q15_Outc:
The majority of calls came from urban population centers such as Houston, Dallas, Austin, and El Paso.  Overall, calls came from 145 of the 254 counties in the state.  In terms of callers, 47.5% were physicians with the remaining 52.5% of calls placed by nurses.  42% of calls came from public-sector agencies while 48% of calls came from private sector health care entities.

In terms of topics focused on during calls, the authors state that “most calls concentrated on questions that relate directly to the diagnosis, treatment, and overall management of infectious diseases” and “concerned problems relating to drug-sensitive or drug-resistant tuberculosis.”  The authors also reflect that the calls have changed qualitatively over the three years covered in the report, as inquiries have shifted from “basic principles and practices” to callers that were “much more informed about TB”

Q16_Limt:
The qualitative component of the calls deserves greater attention and study.

Q17_Conc:
The use of a hotline for dissemination of clinical information about infectious diseases (generally), especially TB is supported by the research.  Additionally, the qualitative changes in call content may reflect advancement of clinical knowledge by providers and supports the continued use of such a hotline.

Q18_Recc:
Further use of hotlines is warranted, as well as additional qualitative study of call topics.


Q1_Title:
Social and Cultural Factors in the Successful Control of Tuberculosis

Q2_Key:
TB, Medical Anthropology, Health Culture, treatment-seeking, treatment adherence.

Q3b_Both:
The article primarily addresses the influences of an individual’s “health culture” on treatment-seeking and treatment adherence (internal), but also discusses the implications of differing health cultures between patient and provider (external).

Q6_ReQue:
The article provides evidence for the importance of examining sociocultural factors in research surrounding treatment-seeking and adherence to TB regimens.

Q7_TheoBas:
Article is guided by literature on Health Culture research.

Q14_Desc:
The article provides several examples of the usefulness of research into the role of health culture and sociocultural factors in TB control.  Specifically, it discusses the need for these measures to be incorporated into research on delays in treatment seeking and adherence to medication-based treatment.  It argues that these factors have been generally overlooked by prior TB research, but are necessary for a full understanding of the disease.

The article focuses on three specific topics to make this argument:
1. the perception and interpretation of TB symptoms and related treatment-seeking
2. the influence of social stigma on treatment seeking and adherence
3. patients’ adherence to treatment regimens

Q15_Outc:
-The most prominent Sociocultural research model is the Health Belief Model (HBM) which can be used to predict individuals’ responses based on sociocultural factors.  Despite its strength, the authors argue that the HBM is not utilized to its full explanatory potential.
-The discussion of symptom perception provides overviews of several studies to examine this topic.  The general message presented by the authors is the strong effect of cultural understandings of the disease on the response among individuals who are symptomatic.  This is supported with evidence from studies in India, Mexico, and the United States.
-The discussion of stigma focuses on the appearance of stigma in various cultures and the adverse implications for TB treatment adherence.  The authors discuss the different cultural issues attached to stigma (such as “dirtiness” or association with witchcraft) in varying locations.  The authors detail the inverse connection between stigma and social support (proven to bolster treatment adherence) to show the issue from a different perspective.
-In the discussion of adherence, the authors detail the key components of some successful interventions to improve adherence and broaden the understanding of the factors contributing to non-adherence.

Q17_Conc:
Overall, the authors present a strong argument for the further inclusion of sociocultural research by illustrating several such impediments to TB control.  The specific impediments discussed are “cultural understandings,” “staff reluctance to adapt their work environments to patients’ daily activities,” and the “sociopolitical organization of health delivery services.”

Q18_Recc:
Recommendations are given at a broad level to support additional sociocultural research.  At a more specific level, the authors provide several recommendations for using focus group sessions for improvement of clinical services through better understanding of sociocultural issues.


Q1_Title:
The Contribution of Medical Anthropology to a Comparative Study of Culture: Susto and Tuberculosis

Q6_ReQue:
Two comparative research efforts to test explanations in anthropology are explored using Susto and TB. The first method looks at cross-cultural comparisons of different groups sharing a region (Susto), and the second is known as within-society comparison (TB). In the Susto study, the authors wanted to study and document occurrences and practices associated with Susto. In the TB study the objective was to explore the feasibility of systematically investigating the influence of concomitant variations among gender, gender roles, and health knowledge.

Q7_TheoBas:
In the TB study, Kleinman’s explanatory model approach was used to explore respondents’ views of respiratory health conditions.

Q11_Intl:
Mexico:  Oaxaca and Mexico: Ensenada and Guadalajara

Q13_Comm:
Descriptives, Chi-square tests, p values,

Q14_Desc:
Results of studies of the popular illness susto and the biomedical entity pulmonary tuberculosis are offered to illustrate how comparisons of sick and well people can elucidate societal processes in cultural anthropology.

Q15_Outc:
1. Susto study
Suffering from Susto (being asustado) had several communalities: distinguished by a comparatively high score on a systematic social stress instrument, revealed more clinical signs and symptoms of clinical disease, and ultimately suffered dramatically higher mortality. 
2. TB study
Within each city, and between each local, there is strong agreement about humoral qualities of six respiratory conditions. There was stronger agreement among women on the humoral qualities of respiratory illness and much weaker agreement among men.

Q16_Limt:
For the TB study, selecting both a tubercular and maximally conservative control group from those presenting with respiratory problems at public health clinics limits generalizability of the results to this Mexican subpopulation

Q17_Conc:
Results from the TB study suggest that the humoral system (1) continues to be important and (2) that is not attenuating. Comparative study results show the feasibility of designing intrasocietal comparative research utilizing signs of disease as the independent variable.


Q1_Title:
Health Care Seeking Behavior of Pulmonary Tuberculosis Patients visiting TB Center Rawalpindi

Q1_Journal:
Journal of the Pakistan Medical Association

Q2_Key:
health care seeking behavior, provider delay, patient delay, tuberculosis

Q3b_Both:
Patients’ delay and health seeking behaviors (internal) were studies as were providers’ delay and utilization of relevant TB examinations and guidelines (external).

Q6_ReQue:
To determine the health care seeking behavior of TB patients in seeking care and health care providers for delivering care.

Q13_Comm:
P values were reported for some findings.

Q14_Desc:
This cross-sectional survey looked into different patterns of health care resorts as adopted by patients in case of an illness and delay in the process of seeking and delivering care.  It examines the health seeking behavior of pulmonary TB clinic patients in Rawalpandi, Pakistan prior to their treatment at TB Center.  The study population was 53% male, 47% female and the majority was of low socioeconomic status.

Q15_Outc:
Prior to their consulting TB Center, 96% patients had already reported to a health care provider, (i.e., to first, second or third health care providers). Of 154 patients, 48 were diagnosed as TB and only 29 (19%) of them received antituberculosis treatment. Most of the patients 118 (77%) consulted the health care provider within 3 weeks time. Study found no gender differences in patient delay.  Health care providers’ delay was found to be 70%, 56%, and 79% respectively in first, second, and third health care providers.  Sputum examination is not used optimally and chest x-ray is overutilized.

Q17_Conc:
Delay is more on the part of health care providers than patients.  Proper implementation of TB program guidelines with public – private sector collaboration and continuing education of health care providers is necessary.

Q18_Recc:
TB control activities should be extended to the private sector practitioners as well as continued medical education in TB diagnosis and treatment.


Q1_Title:
Effects of Acculturation and Psychosocial Factors in Latino Adolescents' TB-related Behaviors

Q1_Author:
Salabarria-Pena, Y., Trout, P., Gill, J., Morisky, D., Muralles, A., & Ebin, V.

Q2_Key:
acculturation, psychosocial, adherence, TB, Latinos, adolescents

Q6_ReQue:
-To determine the effect of acculturation and psychosocial factors such as self-esteem, self-efficacy, mastery, and social support on adherence to TB treatment among Latino adolescents.
-To test educational interventions designed to bolster treatment adherence.

Q7_TheoBas:
None explicitly stated, but based on prior literature showing associations between acculturation and health-related variables.

Q14_Desc:
Adolescents diagnosed w/ TB and placed on medication therapy were randomly assigned to a peer counseling intervention, a parent-adolescent incentive condition, a combination of the two, or usual clinic care.  A series of in-person interviews were conducted at baseline, 2 months, and 6 months from beginning of drug therapy.  Interviews assessed acculturation and psychosocial factors (self esteem, social support, etc.), stigma, and adherence (appointment keeping, completion of treatment, treatment weeks, and number of days medication was missed).

Q15_Outc:
-Differences were found among psychosocial factors based on acculturation, with more acculturated patients more likely to have higher self-esteem and mastery.  Those with higher levels of ethnic identification also had more perceived support from parents.  

-Only age and “difficulty getting to the clinic” were factors significantly associated with adherence.  Older teens had lower acculturation levels, were less likely to complete treatment, and had a lower rate of appointment keeping.

Q16_Limt:
-The measures for “appointment keeping” could have been more accurate by capturing the reasons for missing appointments and rescheduled appointments.
-Medication adherence was measured by self-report and may be vulnerable to self-report bias.
-Some Spanish-speakers had difficulty understanding the Lickert scales in some items.

Q17_Conc:
The study “highlights the importance of parental support and sociocultural factors in adherence to TB treatment in this population.”

Q18_Recc:
“Efforts should be made to address adherence at individual, family, and community levels”


Q1_Title:
Care seeking behaviour and diagnostic processes in patients with smear-positive pulmonary tuberculosis in Malawi

Q1_Author:
Salaniponi, F., Harries, A., Banda, H., Kang'ombe, C., Mphasa, N., Mwale, A., Upinidi, B., Nyirenda, T., Banerjee, A., & Boeree, M.

Q2_Key:
care seeking behavior, diagnosis, smear-positive pulmonary tuberculosis

Q5_Other:
study design not stated; likely cross-sectional

Q6_ReQue:
To determine care seeking behavior and diagnostic processes in patients newly diagnosed with smear-positive pulmonary tuberculosis (PTB).

Q8_SampCom:
1,518 patients   ( 1099 were interviewed)

Q10_AduIntl:
newly diagnosed pulmonary TB patients in Malawi

Q10_ACIIntl:
newly diagnosed pulmonary TB patients in Malawi

Q14_Desc:
The study examined care seeking behavior of newly diagnosed TB patients of government hospitals in 5 districts in Malawi.  1,518 patients were registered with pulmonary TB, of whom 1,099 (72%) were interviewed (522 males, 577 females, ages 9 – 80).

Q15_Outc:
The median delay between onset of cough and diagnosis was 8 weeks.  There was a variable pattern of care seeking behavior, with 70% of patients initially visiting a place of orthodox medical care and 30% visiting traditional healers, grocery shops, etc.  Of these, 867 (79%) patients had one or more subsequent contacts for help, with these visits targeted more to orthodox medical care.  At all stages, antibiotics resulted in symptomatic improvements in up to 40% of all cases.  There was a median time of 7 weeks between cough and first submission of sputum specimens.  Almost all patients received sputum smear results after a median length of 4 days; 474 (43%) of patients were only aware of their diagnosis at the time of receiving smear results, this observation being significantly associated with lack of schooling and not knowing another person with TB.

Q16_Limt:
Not all consecutive patients were interviewed according to the study protocol.  The proportion of patients interviewed was lower at the central hospitals due to the larger numbers of patients and the fact that clinical research officers had other duties to perform.  Nevertheless, nearly three quarters of all patients had their questionnaires evaluated.

Q17_Conc:
More needs to be done to educate communities and non-orthodox care providers about the diagnosis and treatment of TB.

Q18_Recc:
This study shows that patients visit grocery shops, local vendors and private clinics and that in the future it will be important to include these personnel in TB education.  It is equally important to target rural people and villagers who may note have access to school education.  More efforts to inform communities about TB are needed such as use of posters, talks and radio broadcasts on a regular basis; widespread coverage of TB issues on World TB day.  Communities should be involved in case finding and not just treatment and case holding.  Ways to improve case finding need to be found, more suspects who never reach treatment need to be identified, and the time between onset of symptoms and diagnosis needs to be shortened for those who reach treatment.


Q1_Title:
Knowledge of Tuberculosis Among Drug Users

Q1_Author:
Salomon, N., Perlman, D., Friedmann, P., Perkins, M., Ziluck, V., Des Jarlais, D., & Paone, D.

Q2_Key:
TB, knowledge, syringe exchange, compliance

Q6_ReQue:
What is the knowledge of active drug users attending a needle exchange program, of TB and what is their adherence to TB screening (return for TST reading)

Q12_Oth:
Lower East Side Needle Exchange Program (LESNEP)

Q14_Desc:
The authors wanted to examine the TB knowledge of active drug users, and assess the relationship between TB knowledge and attitudes, and return rates for TST at a syringe exchange program in NYC. Individuals who consented to participate were interviewed using a 75 item questionnaire in either English or Spanish, and those who returned for the TST results/reading were provided a $15 incentive.

Q15_Outc:
An independent association exists between TB knowledge and rates of return for skin test reading. 

Active drug users in this program had gaps in knowledge about: TB treatment, prevention and transmission.

Q16_Limt:
Recruitment from a single site (limiting generalizability); and the fact that subjects may have more knowledge of health related issues since they were participating in a harm reduction program.

Q17_Conc:
High acceptance and return rates suggest that TB services can be incorporated into syringe exchange programs.

Q18_Recc:
TB education (and testing) needs to be delivered in settings where drug users congregate


Q1_Title:
Pulmonary tuberculosis and associated factors in areas of high levels of poverty in Chiapas, Mexico

Q1_Author:
Sanchez-Perez, H., Flores-Hernandez, J., Jansa, J., Cayla, J., & Martin-Mateo, M.

Q2_Key:
Pulmonary tuberculosis, Mexico, risk factors, diagnosis, poverty.

Q6_ReQue:
Objective:  To estimate the prevalence of pulmonary TB and factors associated with PTB in areas of high levels of poverty in Chiapas, Mexico.

Q8_SampCom:
1878 Households provided information about 11,274 individuals

Q9_Other:
When potential cases were identified in the interview, sputum samples were also collected.

Q10_AduIntl:
Residents of areas of high poverty levels in Chiapas, Mexico

Q10_ACIIntl:
Residents of areas of high poverty levels in Chiapas, Mexico

Q14_Desc:
Using sampling to the household level in areas of high poverty levels in Chiapas, active case-finding was carried out by interviews with the head of household and subsequent sputum samples of suspect cases.  The rate of pulmonary TB as well as characteristics of living conditions were compared to data for both Chiapas and national averages.  Using logistic regression, several factors were analyzed to assess associations with PTB positivity.

Q15_Outc:
The study found a case rate for TB of 276.9 per 100,000.  None of the socioeconomic or demographic conditions were associated with pulmonary tuberculosis.  Of all variables, only “blood in sputum” was significantly associated with PTB.

Q16_Limt:
The rates estimated in this research may be somewhat skewed due to the fact that active case-finding was carried out with individuals who “had a cough” (at time of interview or in 15 days prior), which may differ from circumstances surrounding measurement by health services in the area.    Due to differences in laboratory methodology, the author estimates that had cases been detected in the same manner as the local health services (using only acid-fast bacilli smears) only 47% of the positive cases would have been identified by the study.

Q17_Conc:
The rate of TB found in the sample population is among the highest in the world.  Only the presence of blood in sputum (and no socioeconomic factors) were associated with pulmonary TB positivity in the regression analysis.  In this area and others studied with high levels of TB and poverty, “it is necessary to develop PTB control programs which give priority (1) to early diagnosis…and (2) to adherence to treatment, due to the possible problems with resistance and the fact that it is in populations of this type where the lowest probabilities of adherence to tuberculosis treatment are found.”


Q1_Title:
Tuberculosis Screening Among Foreign-Born Persons Applying for Permanent US Residence

Q1_Author:
Saraiya, M., Cookson, S., Tribble, P., Silk, B., Cass, R., Poonja, S., Walting, M., Howland, N., Paz, E., Cochran, J., Moser, K., Oxtoby, M., & Binkin, N.

Q6_ReQue:
This study sought to determine adherence of physicians to TB screening guidelines among foreign born persons living in the US who were applying for permanent residency.

Q8_SampCom:
5750 Total applicant; 11 were excluded for incomplete data; 5739 used in the analysis

Q10_AduFrBrn:
Asian, African, Central American, Mexican, South American, Caribbean, Middle East, W. Europe, Japan, Canada, Australia, New Zealand, Israel

Q10_ACIFrBrn:
Asian, African, Central American, Mexican, South American, Caribbean, Middle East, W. Europe, Japan, Canada, Australia, New Zealand, Israel

Q11_USA:
California & New York:  San Diego & San Francisco Counties, CA; New York City, NY; New York State

Q14_Desc:
We evaluated adherence to the CDC’s technical instructions in 5 INS jurisdictions with large numbers of applicants for permanent residence.  Medical forms of applicants were reviewed, along with information from the national physician database on attending physicians.  Applicant and corresponding physician characteristics were compared among those who were and were not screened.

Q15_Outc:
Of 5739 applicants eligible of screening via tuberculin skin test, 75% were appropriately screened.  Except in San Diego, where 11% of the applicants received no screening, most of the inappropriate screening resulted from the use of chest x-rays as the initial screening tool.

Q16_Limt:
Limitations of the study, including the fact that the AMA database did not contain information on 30% of the physician, may have biased the results.  We were also limited in terms of the applicant and physician variables we could examine.  Furthermore, with the wide variability in practices between the study areas, the physicians may not have been representative of all physicians who serve in this capacity, or a few physicians with large applicant volumes may have skewed the results.

Q17_Conc:
Focused physician education and periodic monitoring of adherence to screening guidelines are warranted.  These physicians need to be targeted to adopt appropriate screening practices so as to reduce the prevalence among foreign-born Americans.


Q1_Title:
The relationship between socioeconomic factors and pulmonary tuberculosis

Q1_Author:
Schoeman, J., Westaway, M., & Neethling, A.

Q2_Key:
South Africa, socio-economic factors, general living conditions, luxury items, protein

Q6_ReQue:
Objective:  To discern the similarities and differences between TB cases and controls in order to discover which socioeconomic factors may play a role in the risk of developing disease.

Q8_SampCom:
84  TB patients; 84 disease-free controls

Q13_Comm:
The chi-square test and Fisher’s exact test (two-tail) were used for categorical data and t-tests for continuous data.  Although exact probability levels are reported, the significance level indicative of a difference was kept at 0.05.

Q14_Desc:
The present study was undertaken to ascertain the similarities and differences between TB cases and controls in order to discover which socioeconomic factors may play a role in the risk of developing disease.  Specifically, an attempt was made to develop an appropriate socioeconomic index for local use.  The sample consisted of 168 black urban adults (84 pulmonary TB cases, and 84 controls).

A questionnaire was designed to assess (1) demographic variables, (2) general living conditions (type of housing, number of rooms, number of people living in the house, number of toilets, electricity supply), (3) household ownership of luxury items (radio, TV, and car), and (4) weekly consumption of four proteins (meat, fish, chicken, and cheese).

Q15_Outc:
Demographic Variables:  There were no significant differences between cases and controls on education, marital status, and employment status (Table 1).
General Living Conditions:  No significant differences were found between cases and controls on any of the variables measuring general living conditions (Table 3).  No Significant differences were found between cases and controls on any of the crowding indices (Table 4).
Household Ownership of Luxury Items:  There was no significant difference between cases and controls on ownership of luxury items.
Weekly Consumption of Four Proteins:  Overall significant differences were found between cases and controls on meet (p=0.012) and chicken (p=0.034) consumption, but not for fish and cheese consumption (Table 5).

Q17_Conc:
The present study found no significant differences between TB cases and controls on most demographic variables, general living conditions, ownership of luxury items, and weekly consumption of four proteins.  These findings indicated a lack of evidence on the linkage between individual socioeconomic factors and risk of TB as noted by other authors. 

Risk of developing TB disease is regarded as multi-factorial.  The lack of significant differences between cases and controls from a high incidence group, all of whom lived in the same urban area, suggests the absence of socioeconomic factors in this aspect of the TB disease process.

Q18_Recc:
One would expect socioeconomic differences if black and white people were compared in South Africa.  Such a comparison would be important in future research, although inconclusive evidence regarding the relationship between race and risk of disease might complicate interpretations.


Q1_Title:
Health Education for Tuberculosis Drug Defaulters

Q2_Key:
TB, Health education, defaulters, adherence

Q3b_Both:
This study described internal and external stressors on why a TB patient defaults from treatment.  Results stated: 1. lack of knowledge (internal) about TB; 2. illiteracy and poor socioeconomic status (external) as indicators of poor adherence.

Q6_ReQue:
The present study was conducted with an aim to assess socio-economic and other factors associated with drug defaulters, and the effect of health education in motivation of such.

Q8_SampCom:
225 registered cases; 72 defaulter cases (sample under study)

Q11_Intl:
India:  Singur, District Hooghty, West Bengal

Q14_Desc:
The effect of initial motivation by health education, in terms of regularity of drug collection and the knowledge, awareness and practices of TB drug defaulters were studied in a rural community in West Bengal, India.  The goals of the education program were to help the individual client and his family to acquire knowledge and information on TB and to motivate the client for collection of his drugs regularly.

Q15_Outc:
Findings included: Illiteracy, ignorance and poor socio-economic status were major factors responsible for defaulters.  Feelings of a sense of well-being after consumption of medicine for about one month encouraged the clients to stop drugs.  Most of the TB clients new the name of the disease.  Very few knew that TB was preventable and the ways and means of prevention.  The majority believed that discontinuation of treatment was not harmful.  Clinics’ working time, distance of the clinic from the residences and non-availability of drugs were partially responsible for the dropouts.  Almost all the clients were motivated by the health education program and attended clinics for collection of drugs.

Q17_Conc:
Health education programs play an important role in the motivation of drug defaulters.

Q18_Recc:
It is suggested that follow-up visits and follow-up health education programs by public health nurses and other health workers may solve the defaulter problem of the community in the long run.


Q1_Title:
Patient and health care system delays in the diagnosis and treatment of tuberculosis

Q1_Author:
Sherman, L., Fujiwara, P., Cook, S., LB Bazerman, L., & Frieden, T.

Q2_Key:
TB, diagnostic delay, patient delay, health care seeking delay, diagnosis

Q3b_Both:
Internal (patient delay) and external (health care system delay) are discussed.

Q6_ReQue:
The objective was to examine factors associated with delays in presenting to a health care provider (patient delay) and in starting anti-TB treatment (health care system delay.

Q14_Desc:
All TB patients in NYC who had a specimen that grew M. tuberculosis in April 1994 had been identified for a one-month drug resistance prevalence survey.  Based on medical records and NYC Department of Health Bureau of TB Control record review, the subset of all patients without a history of treatment for TB were chose for this study.  Data was collected on each patient to determine symptom onset, date of patient’s first consultation with a health care provider, initial AFB smear and culture results, initial diagnostic procedures performed, and initiation of anti-TB treatment.

Q15_Outc:
Median total delay was 57 days (range 4–764), 35 for AFB smear-positive patients and 79 for smear-negative patients (P < 0.001).  Median patient delay was 25 days (range 0-731).  Median healthcare system delay was 15 days, 6 for smear-positive patients and 31 for smear-negative patients (P < 0.001).  In logistic regression, age 55-64 years (OR = 10.6, 95%CI 1.3-86.9), and primary language other than English (OR = 2.5, 95%CI 1.0-5.8), were associated with longer patient delay.  Homelessness (OR = 7.1, 95%CI 1.05-33.5), not having a chest x-ray at the first medical visit (OR = 2.4, 95%CI 1.0-5.4), negative smear (OR = 10.2, 95%CI 4.4-23.3) and absence of cough (OR = 2.9, 95%CI 1.2-6.8) were associated with longer health care system, delays.

Q16_Limt:
There are several limitations to this study.  First, were not able to determine the time of onset of symptoms in all patients in the study.  Second, the medical records of some patients who sought care from private physicians were not available, which may have resulted in an underestimation of health care system delays in this group.  Third, there may have been some recall bias from patients regarding type, severity, and onset of symptoms.

Q17_Conc:
To reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care and language services.  Physicians should maintain a high index of suspicion for TB and perform appropriate diagnostic tests.  Addressing both components of delays will decrease the time to treatment and ultimately the extent of transmission of TB.


Q1_Title:
Tuberculosis Research and Control: Anthropological Contributions

Q1_Author:
Shrestha-Kuwahara, R., Wilce, M., Joseph, H., Carey, J., Plank, R., & Sumartojo, E.

Q1_Journal:
Encyclopedia of Medical Anthropology: Health and Illness in the World's Cultures

Q1_Pages:
528-542.  New York: Kluwer Academic/Plenum Publishers

Q6_ReQue:
A review of the TB-focused anthropological and social science literature included in Medline, PubMed, PsychInfo, Gale Business Arts,  Web of Science, SocioFile, and Anthropological Index Online.

Q14_Desc:
This article reviews the complex biological and social factors that impact TB transmission, progression to disease, and treatment. The review focuses on the anthropological and social science literature.

Q15_Outc:
(1) Epidemiological and Medical Features of TB
TB is a communicable disease in humans and has an unequal global distribution. Sputum smears and chest x-rays are most common methods of diagnosis.
(2) History of TB
Theories regarding the origins, spread, and treatment of TB continue to change as new discoveries are made and technologies evolve. Emergence of HIV/AIDS and MDRTB highlighted the severity of the TB issue and called for more social and behavioral approaches to develop effective interventions. 
(3) Social and Cultural Research
The authors reviewed different anthropological and sociological work in regards to TB. Overall there is a gap in research, particularly in theoretical frameworks to examine behaviors. The authors provide examples for understanding care-seeking behavior and adherence issues. Social stigma surrounding TB is universal and has implications for treating patients. Program structure and provider service delivery also impact patient behavior in treatment of TB.
(4) Current Tools and Approaches and Future Directions
The application of research to practice has aided in the development of new tools and approaches to treat TB. Theoretical models and communication between patients and providers have resulted in new interventions. Future TB research must continue to use tools and methods from social scientists – these scientists will play a critical role in the efforts to control and eliminate TB.

Q16_Limt:
While the research is limited in breadth and scope, the results highlight the many implications and applications for TB control practice.


Q1_Title:
Factors Associated with the Treatment of Latent Tuberculosis Infection Among Health-Care Workers at a Midwestern Teaching Hospital

Q1_Author:
Shukla, S., Warren, D., Woeltje, K., Gruber, C., & Fraser, V.

Q2_Key:
Compliance, health-care workers, isoniazid, latent infection

Q6_ReQue:
Objective:  To assess factors associated with initiating therapy and compliance with treatment for latent tuberculosis infection among health-care workers with positive tuberculin skin test results.

Q8_SampCom:
440 skin test-positive health-care workers

Q13_Comm:
A P-value of < 0.05 was considered significant on two-tailed testing.

Q14_Desc:
The purpose of this study was to assess rates of initiating therapy for latent tuberculosis infection among employees at a midwestern teaching hospital with a positive tuberculin skin test results.  In addition, this study sought to identify factors associated with noncompliance with therapy of latent tuberculosis infection among all health-care workers and, in particular, health-care workers with recent tuberculosis skin test conversions.

A total of 440 tuberculin skin test-positive health-care workers were evaluated from January 1, 1994 to May 1, 2000.  Occupational health nurses and physicians evaluated all employees with positive tuberculin skin test results.  Data concerning the employees’ current and prior tuberculin skin test results, medications) received, history of active tuberculosis, previous chest radiographs, and compliance rates were obtained from employee records located in the hospital’s Occupational Health Department.  

Non-compliance was defined as receiving <6 months of therapy or refusal of therapy.  Compliance data were crosschecked with outpatient pharmacy records.

Q15_Outc:
Of the 440 TB test-positive health-care workers evaluated, one health-care worker had presumed active tuberculosis, one had no record of being evaluated, one had missing records, and 33 were not recommended isoniazid therapy, leaving 404 workers for analysis.  Overall, 396 of 404 health-care workers (98%) with positive tuberculin skin test results initiated isoniazid therapy. In univariate analysis, BCG vaccine (p=0.02) and foreign birth (p=0.03) were significantly associated with not initiating isoniazid therapy.  Compliance data were available for 388 of 404 health-care workers (96%).  Of these, 318 of 388 health care workers (82%) were compliant with six months of therapy.  BCG vaccination and symptoms while receiving therapy were significantly associated with noncompliance in multivariate analysis.  Among new converters, Asian race (p=0.006), foreign birth (p=0.01), BCG vaccination (p=0.006), and symptoms while receiving therapy (p<0.001) were significantly associated with noncompliance in univariate analysis.

Q16_Limt:
One major limitation of the study was that patient information, such as past tuberculin skin test dates and test results prior to hire at BJH, along with tuberculosis risk factors, were based on self-reporting.  Thus, information regarding prior tuberculosis test dates could have been subject to recall bias, which could have affected the number of new converters in the study.

Another limitation in this study was the inability to truly decipher between some health-care workers who were not recommended therapy and those who actually refused it.  In addition, insufficient self-reporting led to the inability to analyze certain factors (IV drug use, alcohol use, homelessness, etc) associated with tuberculosis exposure and infection.

Q17_Conc:
In summary, rates of initiating (98%) and completing (82%) therapy for latent tuberculosis infection were high among health-care workers in this study.  Among all health-care workers with a positive tuberculin skin test result, foreign birth, BCG vaccination, and symptoms on therapy were significantly associated with noncompliance.  These findings demonstrate that the teaching hospital in question has effective administrative controls and monitoring practices to promote use of therapy for latent tuberculosis infection and completion of the recommended duration of therapy.  However, continual efforts should be directed toward improving and maintaining measures to maximize initiation of and compliance with therapy for latent tuberculosis infection in order to prevent nosocomial tuberculosis infection among health-care workers.

Q18_Recc:
Foreign-born health-care workers, the majority of whom received BCG vaccination, continue to be a group that is less likely to initiate therapy of latent tuberculosis infection.  This may be largely due to the preconceived notion that BCG vaccination provides lifelong immunity against tuberculosis, along with the inability of the current skin testing method to distinguish between positive results from true infection or vaccination with absolute certainty.  Hence, measure should be taken in order to overcome cultural barriers, which may lead to refusing therapy and noncompliance with therapy.


Q1_Title:
Survey of knowledge, attitudes and practices for tuberculosis among general practitioners in Dehli, India

Q1_Author:
Singla, N., Sharma, P., Singla, R., & Jain, R.

Q2_Key:
KAP study, private doctors, India, X-ray

Q6_ReQue:
Objective:  To investigate the knowledge, attitudes, and practices (KAP) of private practitioners for tuberculosis in Delhi where the Revised National Tuberculosis Programme (RNTP) is being field-tested.

Q13_Comm:
The authors did not calculate the statistical significance of their findings.

Q14_Desc:
A pre-tested questionnaire survey was performed among 204 private practitioners who had enrolled in seminars on tuberculosis in various parts of Delhi.  (The Delhi Medical Association organized a series of free updates on tuberculosis for private practitioners throughout the city.)  This article discussed the results of the survey regarding the knowledge and attitudes of physicians, and the treatment practices that they undertake to cure tuberculosis in their patients.

Q15_Outc:
In a suspected case of tuberculosis, sputum examination was advised by only 12% of the private practitioners (PPs), while 89.5% would recommend chest X-ray.  For treating tuberculosis, 187 PPs were using 102 different regimens, and only 29.4% of PPs were using the regimen recommended by the Revised National Tuberculosis Programme (RNTP).  51.3% of PPs were over-treating their patients.  Only 23.5% of PPs requested sputum examination before the end of treatment, while 35.5% depended on X-ray clearance with clinical improvement.  Only 19.5% of PPs emphasized the importance of regular treatment for their patients.  This study revealed that the PPs maintain no records of their tuberculosis patients, nor do they follow any methodology for retrieval of defaulters.

Q16_Limt:
This study was composed of qualified allopathic doctors with a possible bias towards those who are more interested in attending updates and seminars.

Q17_Conc:
There was a disturbing lack of basic knowledge as well as a lack of progress in the management of tuberculosis.  The majority of PPs are no aware of, and are not following, the recommendations of the Revised National Tuberculosis Programme.  This could be because most PPs are not aware of the RNTP as it is still at the field-testing stage in Delhi.  Furthermore, there are no organized efforts by program managers or by local medical associations to inform doctors.  Only regular training of doctors and proper dissemination of information about the national tuberculosis program can ensure its implementation.

Q18_Recc:
Lack of awareness about the importance of sputum examination could be improved by regular interaction of practicing doctors with medical personnel involved in the RNTP, by means of training, updates, and/or by providing free or subsidized diagnostic facilities.  Training paramedical personnel will also help strengthen local laboratories.  Practicing doctors should be provided with health education, motivation, contact tracing and default retrieval.  The services of social workers would also help in health education, motivation, contact tracing, and default retrieval.

In India, private doctors often provide first contact care to a majority of patients, as well as continuous, comprehensive, on-the-spot services.  The public health sector should make an attempt to reach out to practicing doctors to initiate collaborative efforts.


Q1_Title:
An assessment of default and non-compliance in tuberculosis control in Pakistan

Q6_ReQue:
Objective:  To assess default and non-compliance rates in tuberculosis control in Pakistan

Q14_Desc:
The study was conducted in a rural hospital in the Sind area of Pakistan, where the standard treatment was an 18-month course of isoniazid and thiacetozone, combined with P.A.S. for the first three months.  All patients were being treated for pulmonary tuberculosis, although several also had orthopedic, abdominal, and neurological complications.  The case notes of every patient attending the tuberculosis control clinic at the hospital over a three-year period were studied; these numbered 300.  From this group, both attendance and default patters were assessed.  Default was defined as failure to attend the weekly tuberculosis clinic for a period of one month.

Q15_Outc:
It was found that one year after the commencement of treatment, 66% of patients had defaulted.  Breakdown of the defaulting group (see Figure 1, page 717) shows that the variables investigated have no demonstrable association with non-attendance.  Statistical investigation fails to show any significant difference between the default group and the whole patient population for each variable listed.  Most patients are seen to default after the first or second consultation and virtually 50% have done so by three months.

Q17_Conc:
With an overall default rate of 66% and a non-compliance rate of 53% (P.A.S.) and 60% (isoniazid), clearly much needs to be done in terms of providing patient information that is explicit, can be assimilated by people of different levels of educational attainment, and is reinforced at intervals.  Such an approach needs to be evaluated by monitoring incidence rates for both default and non-compliance.

Q18_Recc:
It is obvious that motivation is the main ingredient lacking in the patients studied.  The answer may therefore lie in the twice-weekly regime suggested by WHO in their general report (WHO, 1974).  A health worker visits the patients twice weekly and administers streptomycin and high dose isoniazid.  This obviously means more labor and more money, but our conclusion is that unless the appalling trends are corrected, attempts at TB control in this part of the world will remain to a large extent inefficient.


Q2_Key:
tuberculosis; health education; learning games; health workers

Q6_ReQue:
Two games are presented in this article that help health workers comprehend the reasons why TB patients often delay in presenting for diagnosis, and why they then frequently default from treatment.

Q14_Desc:
The purpose of this article was to describe how attitudes of health workers, particularly in Nepal, are learned through experiences, and can be developed through simulation exercises such as role plays and games.  The two games mentioned in the article titled, “The Tuberculosis Diagnosis Game” and “The Tuberculosis Treatment Game,” explore the concepts of patient delay and default with health post staff.

Q15_Outc:
The games have been used in the context of a module on human behavior and TB, which is one of four core modules used in skills development with health workers.  The games have been used with over 100 health workers in six workshops, and revised based on trainers’ experiences.  The educational level of the health workers varied from those with a relatively high level of training to those with a relatively low level.  The minimum educational requirement to play these games appeared to be the ability to read.

Q17_Conc:
The usefulness of these games was not in the playing of them, but in the discussion that lead up to and followed them.  The games were a lively and fun way of provoking thought and discussion regarding TB control efforts.

Q18_Recc:
a) For game #1, health care options were appropriate for Nepal, but are not necessarily relevant in other countries.  It is important to use locally appropriate health care options.  

b) The ways of scoring (dice and throwing coins) are widely used in games in Nepal.  However, there may be more appropriate scoring methods in other countries.

c) The games should be translated and used in the local language where they are implemented.


Q1_Title:
The use of socioeconomic factors in mapping tuberculosis risk in a city of northeastern Brazil

Q1_Author:
Souza, W., Ximenes, R., Albuquerque, M., Lapa, T., Portugal, J., Lima, M., & Martelli, C.

Q2_Key:
socioeconomic factors, mapping, tuberculosis, Brazil, social deprivation index, public health surveillance

Q6_ReQue:
Objective:  To identify socio-demographic risk factors statistically associated with TB in Pernambuco, Olinda (Brazil), within defined population bases (populations living in areas with well-defined boundaries), making it possible to construct different levels of aggregation, including census tracts, neighborhoods, and sanitary districts.

Q8_SampCom:
241 census tracts (matched to 1,723 geo-referenced TB cases)

Q9_Other:
Disease Surveillance Warning System, mapping, socioeconomic and demographic characteristics for each census tract

Q11_Intl:
Brazil:  Pernambuco (state), Olinda (city)

Q13_Comm:
P-values (p< 0.01) were reported for several statistical analyses, such as ANOVA, principal component & cluster analyses.  Chi-squared and Kappa tests were used.

Q14_Desc:
Given the magnitude of the problem that tuberculosis (TB) poses for Brazil, the authors chose that disease as an example of how a new, integrated public health surveillance system could be constructed. The authors integrated data from several sources with geographic information to create an indicator of TB risk for Olinda, a city in the Brazilian state of Pernambuco. In order to stratify the urban space in Olinda and to check for an association between the resulting TB risk gradient and the mean incidence of the disease between 1991 and 1996, we applied two different methods: 1) a "social deprivation index" and 2) principal component analysis followed by cluster analysis.

Q15_Outc:
The social deprivation index (SDI) shows that the risk measured by the SDI value rises along with the incidence of tuberculosis for four of the five quintiles described in the study (Table 1, p. 407).  The principal component analysis followed on from the matrix of secondary variables (see p. 406 for a list of variables).  The analysis shows that the distribution of tuberculosis cases in Olinda is not uniform and that there is an association between collective risk, as measured by two different methods, ad tuberculosis incidence rates.  The results of the kappa test showed there was a close agreement between the two methodologies, with principal component analysis followed by cluster analysis validating the social deprivation index method, given the convergence between the areas of lowest and highest risk as indicated by the two approaches.

The best model to explain the relationship between social deprivation and TB is not a linear one.  There appears to be a minimum incidence even when there is no social deprivation, as well as a high level of social deprivation beyond which there is no more increase in the incidence of TB.

Q16_Limt:
One methodological limitation is the fact that the social deprivation index was constructed based on variables of the same weight.  No consideration of the relative importance of each one was taken into account.

Q17_Conc:
The researchers concluded that a new public health surveillance system is needed to replace the conventional epidemiological focus on high-risk individuals and their personal characteristics.  There needs to be a shift in focus toward public health policies that define “high-risk situations,” where environmental and socioeconomic conditions increase the risk of the spread of disease.  The new system would include strict control of acid-fast bacilli smear-positive carriers of pulmonary tuberculosis and their contacts, follow-up of drug resistant cases, and treatment monitoring of cases registered by each health service, according to a geographic approach compatible with the organization of the health services in sanitary districts.

Q18_Recc:
The authors recommend follow-up that would include treating acid-fast bacilli smear-positive pulmonary TB cases, tracing of these persons' contacts, and monitoring of multidrug-resistant cases, all in coordination with local health services.  This article has propose ending the lack of communication among traditional information systems and allowing the interactive analysis of health and sociodemographic data, such as the authors did by integrating Disease Surveillance Warning System and a geographical mapping data sources.  This type of integration could lead or organizing health services on the basis of the health needs of population groups in ways that encompass considerations of quality, quantity, and location.  Additionally, the organization of health services should contemplate the different levels of complexity of health care within each sanitary district.


Q1_Author:
Spence, D., Hotchkiss, J., Williams, C., & Davies, P.

Q6_ReQue:
To determine whether poverty is a factor in the rising trends in TB we undertook a study of rates of TB by area using various indices of social deprivation.

Q14_Desc:
A retrospective study examining the notifications of all forms of TB by council ward over a six year period, 1985 to 1990, and correlating this with four indices of poverty: council housing, free school, the Townsend overall deprivation index, and Jarman, index (aggregate of: number of old pensioners living alone; number of children aged under 5 years; proportion of single parent families; number of unemployed, unskilled workers; people living more than one to a room and those of high mobility) to examine whether the historical link between TB and poverty still exists.

Q15_Outc:
The rate of TB was correlated with all measures of poverty, the strongest correlation being with the Jarman index (r = 0.73, p<0.001).  This link was independent of the high rates of TB seen in ethnic minorities.

Q17_Conc:
We have shown that a strong relation continues between notification rates of TB and poverty in the last decades of the 20th century in the 33 electoral wards of Liverpool.  Our results suggest that where social deprivation is rife, particularly in areas of poor housing, high unemployment, and low income, an increased awareness of TB as a possible diagnosis is necessary.  Far from diminishing, TB both worldwide and in the UK is increasing.  Poverty may be a factor causing this increase.


Q1_Title:
Ngaka ya setswana, ngaka ya sekgoa or both? Health seeking behaviour in Batswana with pulmonary tuberculosis

Q2_Key:
Botswana; Health seeking behaviour; Traditional treatment; Tuberculosis

Q6_ReQue:
The health seeking behavior of tuberculosis (TB) patients, and their beliefs and attitudes with regard to the disease, was studied in 212 Batswana with smear-positive pulmonary TB.

Q7_TheoBas:
Traditional medicine and modern medicine diagnostic processes were discussed.

Q11_Intl:
Botswana:  mainly rural district in southern region

Q13_Comm:
Chi square tests were used to determine statistically significant relationships and 95% CI were reported.

Q14_Desc:
This article provided updated information about the health seeking behavior of TB patients in a mainly rural district in southern Botswana and discussed possible implications for TB work.  Data were collected in a cross-sectional and longitudinal survey of 212 patients (69% male, 31% female) with smear-positive pulmonary TB in Kweneng District in 1993-1994.  Follow-up interviews were conducted with 131 patients (62%) who were asked if they experienced improvement and their planned attendance at traditional or medical treatment.

Q15_Outc:
There is an apparent resemblance between traditional ideas of disease being caused by pollution (i.e., breaking taboos) and modern theories of spread via germs.  TB may be regarded as a “European disease” or a “Tswana disease” and this has implications for health behavior.  All patients were eventually diagnosed and initiated specific antituberculous treatment in a modern health facility. The median number of health facility visits was two, and the median delay period was 12 weeks. 95% of patients visited a modern health facility as their first step of action. Before start of specific treatment one or more alternative treatments was tried by 52% of patients during the delay period. After starting modern treatment, 47% of patients visited, or planned to visit, a traditional healer or a faith healer.

Q16_Limt:
Because the study was conducted in health facilities, one cannot rule out a bias towards under-reporting utilization of traditional medicine or positive beliefs with regard to it.

Q17_Conc:
Traditional explanations of disease seemed less prevalent in 1993/94 than in a study conducted among TB patients in Botswana ten years earlier, but few patients had a thorough understanding of TB from a biomedical point of view.  The majority of PTB patients in Kweneng District attended modern health facilities as their first preference when symptoms have started. Approximately a quarter of patients consulted traditional healers before TB diagnosis was made, whereas half the patients utilize traditional sector after diagnosis.

Q18_Recc:
More knowledge about patients' health seeking behavior and perceptions would be useful for health workers and when developing health education materials. It is important that modern health workers involve the family, especially if compliance problems are anticipated (Kleinman et al, 1978).


Q1_Title:
Tuberculosis in the north-a lifestyle issue

Q2_Key:
TB, Naskapi, screening, environmental and socio-economic factors

Q3b_Both:
The article discusses internal influences on TB such as hygiene and overcrowding, as well as external influences such as access to health care, inadequate water/sewage systems and unemployment.

Q4_Other:
Description of TB & TB control in a specific community

Q6_ReQue:
Description of local TB program and the Naskapi Natives in Davis Inlet, Northern Labrador

Q10_AduIntl:
Naskapi Natives in Davis Inlet, Northern Labrador, Canada

Q10_ACIIntl:
Naskapi Natives in Davis Inlet, Northern Labrador, Canada

Q14_Desc:
The article described TB and related health education efforts for Naskapi natives in the Davis Inlet (population ~320) in Northern Labrador, Canada.

Q15_Outc:
The fundamental causes of TB exist in the environmental and socio-economic climate, which prevails in northern Canadian communities such as Davis Inlet.  The combination of overcrowding, limited employment, and the ensuing stress along with inadequate hygiene provides a favorable environment not only for reactivation of TB but also for dissemination of the disease.  In the past, problems with drug regimen compliance have been related to alcohol abuse and the tendency for some individuals to leave at short notice.

Q17_Conc:
Health education on TB in this Naskapi community has emphasized preventive measures relating to such predisposing factors as hygiene, overcrowding, alcohol abuse and nutrition.  In many instances, improvements in these areas lie outside the health workers’ jurisdiction.  The combination of conditions which give rise to TB are common to most other predominant health problems in the community. Any improvement in the standards of living of the people of the North can only lead to a general improvement in their health and quality of life.

Q18_Recc:
A comprehensive program to combat TB involves not only case-finding and ensuring that medication regimes are followed but also an approach to health education which involves the participation of the people in their own health care once again and creates an awareness of the real causes of ill health.


Q1_Title:
The Combating of Tuberculosis: Health Perceptions, Intentions and Vaccination of Children

Q2_Key:
compliance; isoniazid; tuberculosis; homelessness; South Africa

Q6_ReQue:
The aim of the research was to examine factors influencing black people’s health perceptions and intentions concerning the combating of tuberculosis as well as the vaccination of their children.

Q13_Comm:
Only associations significant at the 10%-level between the dependent and independent variables were discussed.

Q14_Desc:
The purpose of the study reported here was to establish the role in certain black areas of the factors posited by the Health Belief Model in individual health perceptions, intentions to combat tuberculosis and previous vaccination of respondents’ children.  The study was part of a comprehensive research project undertaken at the request of the SANTA Health Education Committee to evaluation the tuberculosis guidance program.  The research was conducted in selected areas of the Orange Free State, South Africa in two areas called Transvaal and Natal.

Q15_Outc:
Factors indicating a greater degree of development of the individual (e.g., literacy) were positively associated with positive health perceptions such as that medical treatment can cure TB completely.  Some positive associations were also found between perceptions/modifying factors and intentions/vaccination.  Indications were also found of an inability on the part of the health personnel to influence the public positively.

Q17_Conc:
Individual health perceptions:
Respondents with a higher level of development, in comparison with the rest, accepted more responsibility for their health and believed that they had control over it and would therefore be less likely to view the possible effects of TB on their personal circumstances as serious.  

The negative associations between receiving the information from friends/relatives and positive health perceptions indicate that information received in this way may in fact be harmful to the combating of TB.  Also, the lack of positive associations between the receiving of information from health personnel and health perceptions indicate an inability of the health personnel to reach the general public with effective health messages.

Prevention of TB and vaccination of children:
The perception of the seriousness of TB played a lesser role while the perception of susceptibility shows no associations with intentions or vaccination.

Q18_Recc:
Implications for health education:
The importance of a situation analysis before commencement of a health education program to identify the target group and its characteristics.
The importance for health personnel of using the vaccination situation to convey information about the prevention of TB.

The importance of furnishing the general public with correct information especially about the susceptibility to TB and the benefits of medical treatment; the role that mass media can play in distributing the health message.

The necessity to incorporate people with characteristics of a higher level of development, for instance the ability to read well, into the preventive effort.

The urgent need for community development.


Q1_Title:
Communication with TB Patients; A Neglected Dimension of Effective Treatment?

Q1_Author:
Steyn, M., Merwe, N., Dick, J., Borcherds, R., & Wilding, R.

Q2_Key:
tuberculosis; communication; South Africa; nurses

Q6_ReQue:
The purpose of the study was to investigate the quality of the communication in the interactions between clinic nurses at a Western Cape clinic and newly notified tuberculosis patients.

Q8_SampCom:
5 professional nurses; 10 newly notified TB patients

Q9_Other:
Nurses’ interviews with TB patients were videotaped

Q14_Desc:
The purpose of the study was to investigate the possibility that the interviews conducted at the Cape Town City Council clinics with newly-notified TB patients could be more effective if training in communication skills were offered to the clinic nurses.  The researchers conducted a first assessment of 5 professional nurses and 5 newly-notified TB patients.  The second phase consisted of a 5-session training program, which introduced the nurses to the concept of a patient-centered interview and within a mutual process in communication.  The third phase consisted of a repetition of what was done in the first phase.

Q15_Outc:
All nurses showed a consistent improvement in their score after the training but there were some difference in the degree of change as the profiles did not appear parallel.

Q16_Limt:
The research design introduced a number of potential biases in that a different patient was interviewed before and after the training intervention, and 4 of the 6 assessors knew which interviews had been conducted prior to the training.  Also, patients responded to questions in such a way as to avoid offending the researchers (social desirability).

Q17_Conc:
After receiving training, the nurses’ interviews with patients revealed a significant shift towards a more patient-centered approach, resulting in mutual satisfaction of nurse and patient.

Q18_Recc:
Training in communication skills should be introduced at TB clinics in order to improve patients’ adherence to therapy.


Q1_Title:
Adherence to the Tuberculosis Treatment Plan

Q1_Journal:
Tuberculosis: A Sourcebook for Nursing Practice

Q1_Pages:
121-136. New York: Springer Publishing Company

Q3b_Both:
Chapter describes both domains in discussion of adherence

Q6_ReQue:
To discuss and describe components of patient adherence

Q14_Desc:
This chapter describes the problem of poor patient adherence, ways of measuring adherence, factors found to affect adherence, and findings from research on patient adherence to medication for TB and suggests approaches for improving adherence.

Q15_Outc:
Patient adherence can be measured directly and indirectly, but it is difficult to predict adherence. Individual patient factors (i.e., age, gender, etc.) are inconsistent predictors of adherence and providers should instead consider environmental, structural, and operational aspects. Strategies to improve adherence include developing a partnership with the patient, educating the patient, including patients in the treatment process, and considering different cultural beliefs. Although not foolproof, DOT is recommended as a strategy for patient adherence. Finally, other strategies such as drug injections, incentives, and comprehensive services are good alternatives to assist patients in adhering to drug treatment.


Q1_Title:
When tuberculosis treatment fails. A social behavioral account of patient adherence

Q2_Key:
social behavioral theory, TB, treatment adherence

Q3b_Both:
Article is a lit review of adherence-related studies that span both domains.

Q6_ReQue:
The two explicit goals of the article are to provide a background for adherence researchers and to challenge TB controllers to take innovative and comprehensive approaches to programming.

Q7_TheoBas:
Thesis: “Generally, the reasons for poor adherence are not only multifaceted and complex but range from characteristics of the individual patient to qualities of the social and economic environment that influence all TB prevention and control activities”

Q14_Desc:
The article summarizes some of the existing social behavioral research surrounding adherence to TB treatment.  It describes the scope of non-adherence, the methods used to measure adherence, factors that can explain or predict non-adherence.  It then summarizes various research into cultural factors related to non-adherence and provides a well-organized overview of several interventions initiated to bolster adherence.

Q15_Outc:
The author discusses the broad scope of nonadherence, which some estimates show to occur in 25% of cases of active TB in the US.  This problem is complicated by the lack of a uniform standard of measurement for non-adherence, although several measures (such as urine assays, pill monitors, etc.) have been recently developed to aid in monitoring of adherence.  Overall, evidence points to the need to use multiple measures when assessing adherence.

Research into factors that predict non-adherence has resulted in a list of such factors ranging from homelessness, substance abuse, unemployment, illiteracy, and low income to those such as environmental and structural barriers.  Additionally, demographic factors have used in the literature, but are not effective in predicting adherence.  The best predictor is a patient’s own history of adherence with prior regimens, although this is often impractical.

Several cultural factors have been examined for their role in adherence.  The author cites a wide array of varying cultural beliefs and their impacts on adherence, and discusses several ways in which TB services have been made more culturally appropriate.  This discussion gives way to a broader presentation of interventions designed to improve adherence, such as incentives (both monetary and social), education, Directly Observed Therapy (DOT), the use of community health workers, and integrated comprehensive TB services.

Q17_Conc:
“TB has entered a dangerous new era.”  Because of the threat of TB resurgence, the need for creative comprehensive programming is very great and must include addressing social and behavioral dimensions of treatment adherence.

Q18_Recc:
“More systematic, theory-based work needs to be done by TB researchers.”  This should be done to better identify predictors of non-adherence in varying situations and establish strategies to minimize its occurrence.


Q1_Title:
Can Physicians Treat Tuberculosis? Report on a National Survey of Physician Practices

Q1_Author:
Sumartojo, E., Geiter, L., Miller, B., & Hale, B.

Q2_Key:
TB treatment, Survey, adherence, provider, CDC, ATS, recommended practices

Q6_ReQue:
The aim of the study was to assess whether physicians would follow recommendations of the CDC and ATS for TB treatment.

Q11_USA:
US (states not specified):  nationwide / states not specified

Q14_Desc:
A national survey was conducted of physicians to assess whether they would follow recommendations of the CDC and ATS for TB treatment extant in 1992 Physicians practicing in areas that reported at least 5 cases of TB between 1985 – 1989 were selected from the American Thoracic Society database of active physicians.  Respondents were asked to describe 1 example of the usual regimen they use or would use in treating active TB.

Q15_Outc:
Among respondents, 59.4% described a recommended regimen.  Specialists; physicians aware of professional publications, treatment recommendations, and reporting requirements; and those having more than 50% of patients in nursing homes were more likely to describe recommended regimens.  Physicians who had been in practice longer, relied on personal experience, or had more than 50% of patients receiving Medicare were less likely to describe recommended regimens.  Respondents were primarily private sector providers.  24% - 29% of specialists described a regimen of too long a duration and 5% described a regimen that could lead to further transmission and drug resistance.

Q16_Limt:
The limitations to this study reflect the limitations of surveys.  Busy respondents may not have answered the questionnaire carefully; they may have referred to a colleague or to a published resource for the correct treatment regimen (if this were so, however it seems that more would have described correct regimes).  Validation of responses (e.g., reviews of patient records) was not within the scope of this study.  Nearly half of the original sample did not respond, and foreign-trained physicians were underrepresented.  Non-respondents and respondents may have had different knowledge about TB; if so results would represent better informed physicians.

Q17_Conc:
Physicians who treat TB require training and support.  Policymakers should consider who should treat TB and how recommended practices should be ensured.

Q18_Recc:
The data point to the need for guidelines that emphasize the public health importance of adherence to treatment recommendations for TB.  Treatment information must be available to physicians in a variety of formats so that it is accessible and useful.  Use of this study as a baseline for additional studies of providers knowledge and use of treatment recommendations.


Q1_Title:
Variations in National Health Care Practices and Behaviours and Their Influence on International Research

Q2_Key:
International Union Against Tuberculosis, multinational trial, isoniazid, Eastern Europe

Q6_ReQue:
Objective:  To conduct an international trial of INH preventive therapy for tuberculosis to demonstrate how inter-country variations in health care practices can influence study outcomes.

Q8_SampCom:
7 countries; 115 participating dispensaries; 27,830 participants  (see Table 1)

Q11_Intl:
Czechoslovakia, German Democratic Republic, Finland Hungary, Poland, Romania, and Yugoslavia

Q13_Comm:
Results were considered statistically significant if the P value was < 0.05

Q14_Desc:
For this trial, the International Union Against Tuberculosis (IUAT) required a large population of infected, but previously untreated, individuals.  Because no one country expected to be able to provide the required number of study subjects, seven eastern European countries which rarely used INH preventive therapy as a part or of their tuberculosis control programs agreed to enter patients into the trial.  The focus of this paper has been limited to those cross-cultural problems that most directly affected the three major study outcomes:  the development of tuberculosis disease; potentially drug-related adverse reactions; and completion of therapy.

Participants were recruited from seven countries, each of which provided a national coordinator who was responsible for selecting local dispensaries for participation.  Participants who entered the trial were randomly assigned to one of three treatment durations.  In each dispensary, one-third of the participants were to receive pills for 12 weeks, one-third for 24 weeks, and one-third for 52 weeks. Within each duration group, three-quarters of those assigned were to receive INH and one-quarter received a placebo.

Using both the participant’s testimony and the returned pill calendars, dispensary personnel also recorded the number of pills removed from each calendar on the treatment record.  A participant was considered “compliant” if > 80% of the medication had been removed fro each monthly pill calendar.  Five annual health examinations were scheduled on or close to the anniversary of the admission examination.  At each examination, a sputum specimen for culture and a chest radiograph were obtained.

Q15_Outc:
Inter-country variation in the incidence of stopping treatment because of drug side effects and uncooperativeness ranged from 2% (Country C) to 6.2% (Country F).  As with the other characteristics, variation in the proportion of uncooperative participants from country to country was greater than variation among dispensaries within countries (F=5.31, p<0.0001).

The percentage of participants from each country who were noncompliant but did not discontinue treatment (Table 4) ranged from 11.8 in Country C to 27.8 in Country G.  Again, the variation was significantly greater from country to country than within countries (F=9.82, p<0.0001).

Q16_Limt:
In this trial, the risk of tuberculosis varied from country to country, as did the rates of cooperativeness, adverse reactions, completion, and compliance.  When data from various countries were pooled for analysis, the population and results were no longer characteristic of any one of the participating countries.  This created difficulties for those who wished to use trial results to establish treatment policies in any given country.

Q17_Conc:
Despite the drawbacks, multinational clinical trials can be valuable.  The heterogeneity among participants in different countries increases the ability to generalize the results.  Furthermore, a multinational trial may be the only way to gather a sufficient number of participants to investigate an important research question.  With appropriate planning, data collection and analysis, multinational trials can contribute greatly to the understanding of global health problems.

Q18_Recc:
Because differences from country to country may influence study outcomes, researchers must be alert to such differences.  In planning trials, organizers and planners should identify in advance known or potential differences (heterogeneity) among countries that may enhance or obstruct the achievement of the trial objectives.   Particular attention should be paid to differences related to the treatments or outcomes under study.  If these potential differences might impact upon the trial results, data collection forms or questionnaires should be designed to measure these differences and the study methods should be designed to avoid or minimize confounding effects.  Although it is possible to adjust for difference sin the analyses, it is best to identify potential differences in advance and use this information to influence study design and data collection methods.


Q3b_Both:
This research study looked at the patients’ perspectives on how TB affected their lives, especially how it affected their employment opportunities, in receiving treatment, etc.—factors that can be considered external (structural) barriers.

Q6_ReQue:
To discover the impact of contracting TB on the life of a group of urban black working-class people, and its effect on employment opportunities and social life.  In this study, patients’ views on the matter were ascertained.

Q13_Comm:
Chi Mantel-Haenszel test (Refer to additional comments)

Q14_Desc:
A survey was conducted on urban black working class TB patients in Cape Town, South Africa.  Aspects such as the impact of contracting TB on employment opportunities and social life, difficulties in getting treatment, and knowledge of TB were studied in this sample population.

Q15_Outc:
The high rate of unemployment among TB patients throws a heavy burden of support on family members.  Poor housing, particularly overcrowding, is known to be associated with TB.  Very few people felt that their disease had affected their relationship with friends and family.  Passive case finding is seen as the most important method in South Africa.  This study showed that no one in the sample suspected they had TB.  Often non-compliance is seen as the fault of the patient.  In this study, over 50% of the sample had problems in getting treatment; distance from the clinic was an important factor.  Finally, people showed very little knowledge of the signs and symptoms of TB, its prevention or the duration of treatment.

Q17_Conc:
Weaknesses in the implementation of present TB policy:
1) Insufficient attention is given to socio-economic factors (i.e., whether TB can be controlled while people live in overcrowded circumstances with very limited means of support;
2) The problems of having to get treatment at a centralized health service are underestimated; treatment at home or at work would be of great assistance, particularly to women with small children and people in employment;
3) The ineffectiveness of health education at present – continuing of evaluation of both methods and results is required.


Q1_Title:
Health-seeking behavior of individuals with a cough of more than 3 weeks

Q3b_Both:
The article discusses gender differences and biases related to health-seeking behaviors (external) and the specific actions taken by men and women to seek health care (internal).

Q6_ReQue:
This population-based survey assessed health-seeking behavior in males and females (ages 15 & over) with long-term cough in Ha Tay province, Vietnam.

Q8_SampCom:
34,127 surveyed.  492 had a cough of >3 weeks (213 MEN + 279 WOMEN).

Q10_AduIntl:
Males (213) and females (279) ages 15-60 in Ha Tay province, Vietnam with a cough lasting  >3weeks

Q10_ACIIntl:
Males (213) and females (279) ages 15-60 in Ha Tay province, Vietnam with a cough lasting  >3weeks

Q13_Comm:
Several findings with and without statistical significance were reported.  Several p values were reported.

Q14_Desc:
The article discussed the health-seeking behaviors of men and women (ages 15-60) based on a population-based survey of 34,127 in Ha Tay province in Vietnam. Household interviews identified 492 (1%) individuals who had a cough lasting >3 weeks during the 3 months before the study.

Q15_Outc:
253 (91%) women and 188 (88%) men reported having taken a health-care action.  44 (16%) women and 18 (7%) men reported 3 or more health-care actions.  Women took more health care actions than men, but chose less qualified providers and reported lower health expenditure per visit.  Delay before seeking hospital treatment was longer for women (41 days) than men (19 days; p=0.04), and more men (27; 36%) than women (14; 14%; p=0.0006) reported giving a sputum sample at hospital.  About 10% (51) of both men and women with long-term cough did not seek health care at all, indicating a failure of the national health program to reach parts of the population.

Q17_Conc:
The findings indicate a sex bias in tuberculosis case detection and are in accord with those of an earlier study in Vietnam showing longer doctor delay to diagnose tuberculosis among women.

Q18_Recc:
In a high-incidence setting, tests for tuberculosis need to be widely available to allow success in the tuberculosis program.  Sex-sensitive strategies taking into account the observed sex differences in health-seeking behavior and addressing the neglect of case detection thus need to be developed.


Q1_Title:
Adherence to Isoniazid Prophylaxis in the Homeless

Q1_Author:
Tulsky, J., Pilote, L., Hahn, J., Zolopa, A., Burke, M., Chesney, M., & Moss, A.

Q6_ReQue:
To test 2 interventions to improve adherence to isoniazid preventive therapy for TB in homeless adults.

Q8_SampCom:
118 subjects total: 43 were in the monetary incentive arm; 37 were in the peer health adviser arm; 38 were in the usual care arm

Q12_Oth:
Free meal programs; low-cost residential hotels in inner-city neighborhoods

Q13_Comm:
Wilcoxin rank sum tests were used for analysis of continuous variables; Chi square test or the Fisher exact test were used for analyses of categorical variables.

Q14_Desc:
Researchers conducted a randomized control trial using two interventions to improve adherence to isoniazid preventive therapy for TB in homeless adults.  The study compared 1) biweekly directly observed preventive therapy using a $5 monetary incentive and 2) biweekly directly observed preventive therapy using a peer health adviser, with 3) usual care at the TB clinic.

Q15_Outc:
The primary outcome of the study was completion of 6 months of isoniazid preventive therapy as documented by the TB clinic chart.  Completion in the monetary incentive arm was significantly better than in the peer health adviser arm and the usual care arm.  The difference between the peer health adviser and usual care arms was not statistically significant.  Only housing status at the time of entry into the study was a statistically significant predictor of adherence to 6 months of isoniazid therapy.  Subjects who were literally homeless living in a shelter or on the street were less likely to complete treatment than those living in hotels or apartments or living with friends.  This study found no association between the variables of drug/alcohol use and mental illness with adherence.  Also, race, sex, or age were not predictive of adherence.

The researchers observed two specific barriers to adherence: 1) distance between the neighborhoods where most of the homeless spend their time and the county hospital where the TB clinic and the monetary incentive arm were based, and 2) jail.

Q16_Limt:
The peer health adviser intervention is 1.5 times as expensive as the monetary incentive intervention.  Additional training to peer health advisors would have increased the cost of the intervention.

Q17_Conc:
A $5 biweekly case incentive improved adherence to TB preventive therapy compared with a peer intervention or usual care.  Living in a hotel or apartment at the start of treatment also predicted the completion of therapy.

Q18_Recc:
Improving access by providing a convenient downtown site for DOPT may improve adherence.  Regarding the peer health advisors arm, additional training in problem solving with clients, and also a higher level of supervision may also have improved adherence in this arm. 

Twice weekly DOPT with a $5 incentive should be considered as a prevention strategy by jurisdictions with large numbers of TB cases among the homeless and marginally housed.


Q1_Title:
Street talk: knowledge and attitudes about tuberculosis and tuberculosis control among homeless adults

Q1_Author:
Tulsky, J., White, M., Young, J., Meakin, R., & Moss, A.

Q6_ReQue:
What does the study population know about TB and where do they get their information?  Do they believe they are at risk of TB, and what are their attitudes towards control measures used to improve treatment adherence?

Q14_Desc:
The unit of analysis is individual homeless persons from five homeless shelters in San Francisco, which represent 90% of the homeless beds for single adults in San Francisco.  All shelter clients who spoke English or Spanish were asked to complete a 10-minute interview.

Q15_Outc:
Over 60% of the participants had misconceptions about TB transmission (most confused it with HIV transmission). Over half were concerned about catching TB and most favored controls to ensure adherence including DOT. Subjects who knew more about TB and who were male were more favorable towards DOT.

Q16_Limt:
Due to the use of a cross-sectional design, no temporal or causal relationships can be interpreted.  The study subjects may not be representative of homeless persons (the high refusal rate implies a self-selected group).  The study also has the potential for bias because of self-report.

Q17_Conc:
Health care providers need to expand their educational messages about TB beyond skin testing. Increasing social norms about completion of therapy may improve treatment outcomes in this population.

Q18_Recc:
More focus needs to be directed to the motivational determinants in this population.  An assessment of the homeless and their special needs should be done so that interventions can be tailored to the perceived and real issues influencing their adherence to a program for the identification and management of TB.


Q1_Title:
Can the poor adhere? Incentives for adherence to TB prevention in homeless adults

Q1_Author:
Tulsky, J., Hahn, J., Long, H., Chambers, D., Robertson, M., Chesney, M., & Moss, A.

Q2_Key:
latent tuberculosis infection; homelessness; adherence; incentives; randomized trial

Q6_ReQue:
To compare the effect of cash and non-cash incentives on 1) adherence to treatment for latent tuberculosis infection, and 2) length of time needed to look for participants who missed their dose of medications.

Q8_SampCom:
119 participants (65 in the cash arm; 54 in the non-cash arm)

Q12_Oth:
Free meal programs; low-cost residential hotels

Q13_Comm:
Bivariate analyses used Chi square or Fisher’s exact test for categorical variables and Mann-Whitney test for ordered qualitative and continuous variables.  Multivariate analyses used forward stepwise logistic regression.

Q14_Desc:
The study compared cash with non-cash incentives for DOPT delivered at a community site to a population of homeless and marginally housed adults.  The researchers examined: 1) completion rates for preventive therapy and 2) hours of follow-up needed for participants who missed appointments.  Factors associated with completion and those associated with requiring more follow-up time were identified.

Q15_Outc:
86% of the participants completed preventive therapy for LTBI.  There was no significant difference in completion rates between the cash and non-cash groups.  In multivariate analysis, male sex and housing status at entry independently predicted completion of preventive therapy.  In a forward stepwise logistic regression, cash incentive, no history of crack cocaine use, and prior history of INH were independent predictors of needing less time for follow-up.  The total cost of incentive-enhanced DOPT was $460.98 per participant in the cash arm and $494.45 in the non-cash arm.

Cash incentive was not independently associated with completion of therapy as it was in previous studies conducted by the researchers.  The current study suggests that cash itself may not be the critical element in producing successful adherence, as much as the application of any consistent, predictable, positive incentives.  This study reported the first systematic documentation of time needed for follow-up with indigent patients.  Significantly more follow-up was needed by those in the non-cash arm, crack cocaine users, and those with no history of INH.

Q17_Conc:
The results show that modest incentives in a structured program can produce an effective public health intervention in a typically poor, urban indigent population.  Incentives are a valuable way to help a person overcome barrier to complete a course of DOPT.


Q1_Title:
Screening for tuberculosis in jail and clinic follow-up after release

Q1_Author:
Tulsky, J., White, M.C., Dawson, C., Hoynes, T.M., Goldenson, J., & Schecter, G.

Q2_Key:
Jail, preventive therapy, screening, San Francisco, inmates, isoniazid, Hispanic

Q6_ReQue:
The purpose of this study was to describe tuberculosis (TB) screening and preventive therapy in the San Francisco County Jail and to measure the follow-up rate at the public health department TB clinic.

Q14_Desc:
The purpose of this study was twofold.  First, researchers examined the TB screening program at the San Francisco County Jail, and studied the characteristics of the inmates on isoniazid.  Second, researchers documented the follow-up rate at the county TB clinic among inmates released prior to isoniazid completion.

Q15_Outc:
Of 3352 inmates screened, 553 (16.5%) reported a prior positive skin test, and 330 (26.9%) of 1229 tests placed and read were positive.  Of those with positive tests, 151 (45.8%) began isoniazid.  Most of the inmates were foreign-born Hispanics (80.8%).  Ninety-three (61.6%) inmates were released before completion, after an average of 68.5 days.  Three (3.2%) went to the TB clinic within a month.

Q16_Limt:
First, this study was limited to men, and TB screening and preventive therapy should also be characterized among women.  Second, the lack of information on HIV infection status and the insensitivity of the PPD skin test among intravenous drug users might have resulted in an underestimate of the prevalence of TB infection.  Third, researchers were unable to determine whether individuals went too other sources of care for isoniazid continuation.  TB infection care is free, however, at the San Francisco TB clinic, which should encourage individuals to obtain care there.  The authors of the study believe it unlikely that, among individuals who moved, a large proportion would have found another source of TB preventive care within a month.  Finally, a first contact with the TB clinic after release does not indicate completion of preventive care.  A more complete study is warranted.

Q17_Conc:
Jails are effective sites for screening to detect active TB.  Persons who are jailed include those in high-risk groups for developing active TB (e.g., individuals who use illicit drugs, who have been in shelters and other congregate living sites, and who are at high risk of being HIV positive).  A high proportion of TB infection in this study occurred among foreign-born individuals with less than five years’ median time since immigrating from areas of high prevalence; this group has also been identified as at risk for developing active TB.

In a 1992 US survey, however, 48% of 31 large jail systems did not record TB infection rates.  The demographic characteristics and the rate of Tb infection in this study population show the potential yield in screening for infection in jails as a strategy to control TB in future decades.

Q18_Recc:
There is a public health obligation that preventive therapy begun in the jail should be completed in the community.  A system is currently being implemented in San Francisco whereby inmates will be given a month’s supply of isoniazid at release.  There are two issues of concern for every jail:  (1) whether preventive TB treatment should be started in a facility where the length of stay is short, and (2) whose responsibility it is to ensure that preventive therapy is completed in the community.  The second issue is more difficult in an era of diminishing health care resources.  The responsibility for ensuring that preventive therapy is completed rests in liaisons between correctional health services and the public health system.


Q1_Title:
Prominent Shortcomings and Possible Interventions

Q1_Pages:
63-77.  Bombay: The Foundation for Research in Community Health

Q3b_Both:
Article talks about social and operational constraints in controlling TB.

Q6_ReQue:
This chapter analyzes the perceptions and actions of the providers and beneficiaries of the TB program in India. The study uses a holistic approach that encompasses a long period of time and focuses on a specific district in the TB program.

Q14_Desc:
The chapter describes the genesis of the shortcomings of the users and provides of TB control services in India, and discusses possible solutions.

Q15_Outc:
The shortcomings of the TB control program are mismatch in priority (between patients and TB program); using a medical approach to a public health problem; alienating the private sector; lack of proper training; poor access to the people; and difference in dogmas infesting the program. 

Solutions to social and operational constraints in controlling TB are defined as symptomatic (interventions easy to implement and may show quick results) or systemic (broad measures to improve TB control). Symptomatic interventions include information and education; participation of program managers in the TB program; and training and involving NGO’s and private doctors. Systemic measures include epidemiological, technological, economic, and socio-political considerations.

Q17_Conc:
Research should help optimize the present TB program operations and include more systemic measures. The chapter concludes by talking about reorganization of levels within the TB district.


Q1_Title:
Alternative Approaches to Improve Treatment Adherence in Tuberculosis Control Programme

Q2_Key:
India, non-adherence, non-governmental organization (NGO)

Q6_ReQue:
Objective:  To assess the alternative approaches adopted by two NGOs—one urban and the other rural—to achieving desirable levels of tuberculosis treatment completion and cure rates.

Q8_SampCom:
117 urban NGO patients; 223 rural NGO patients

Q9_Other:
Qualitative information was obtained by informally talking to the functionaries of the clinic and those working in the field

Q14_Desc:
This paper discusses alternative approaches successfully employed by two NGOs—one urban and the other rural—to achieve desirable levels of treatment completion and cure rates.  While both NGOs had maintained excellent records, none had ever performed cohort analysis.  This was done for the first time in the present study.  

The urban NGO had eight clinics in western Bombay.  Qualitative information was obtained by participatory observation, informally talking to the functionaries of the clinic and those in the field, examination of available records, and a cohort analysis of all the patients registered for treatment during the period of January 1, 1992 and December 31, 1992.  The rural NGO was located in the state of Gujarat, and had qualitative information collected in the same way.    A cohort analysis of patients registered for treatment between January 1, 1993 and December 31, 1993 was carried out.

(For a detailed description of the NGOs’ procedures for selecting and monitoring patients, see page 69.)

Q15_Outc:
Urban NGO:  At the end of six months, 74% of patients had collected all of their drugs, and 77% of patients had collected at least 80% of their drugs.  The cure rate was 70%.  (See Figure 1, page 70.)
Rural NGO:  At the end of six months, 81% of patients had collected all of their drugs, and 86% of patients had collected at least 80% of their drugs.  The cure rate was 84%.  (See Figure 2, page 71.)

Both NGOs working in entirely different settings evolved ways of achieving high treatment completion and cure rates by adopting innovative ways of treatment adherence:
1) Each NGO had a good reputation and the confidence of their clients.
2) All patients were subjected to sputum examination as well as X-ray of the chest before making a diagnosis.  It is believed that the association of x-ray chest, as an investigation necessary for diagnosing tuberculosis, is so strong in people’s mind that subjecting them only to sputum microscopy might fail to confidence people about the veracity of the diagnosis of tuberculosis, resulting in the loss of confidence in the service.
3) Both organizations provided short course chemotherapy, and ensured regular drug supply.
4) Ample time and efforts were spent on educating the patients and their peers and families.

The weakest component of the TB programs of both the NGOs was the ineffective use of their records.

Q17_Conc:
The oft-repeated question is whether such closely managed NGO programs are replicable and suitable to be adopted nationally through the public health system of India.   If the success of these two NGOs provides any indication, it is primarily the locally suitable alterations, made within a sound framework, that help such organizations to enhance their performance considerably.  If so, efforts need to be directed to modify the revised National Tuberculosis Programme strategy, to the extent possible, so as to afford flexibility by allowing for local alterations and adaptations, like involving ICDS workers or leprosy program workers without disturbing the basic tenets of the program.  It is only then that the social and operational constraints that continue to plague the NTP may be effectively addressed.

Q18_Recc:
It was observed that the urban NGO was exercising “case selection” for purposes of treatment to exclude patients belonging to the floating migrant population, non-residents and cases straying too far outside the project area.  However, such cases were started on treatment and advised to continue treatment from a public health facility.  This policy of selecting cases may be considered unacceptable on ethical grounds and even artificially improving the treatment outcome.  Yet, if the criteria are laid down carefully, “case selection” may deserve serious consideration in urban areas because such an approach may improve treatment adherence by curbing the well known “shopping for treatment” by tuberculosis patients.  This may not be unethical, particularly when such patients have an equally easy access to other free and for-profit health providers.


Q1_Title:
Provider Perspectives: Public Providers and Private Doctors

Q1_Pages:
33-62.  Bombay: The Foundation for Research in Community Health

Q2_Key:
India, public health services, private medical practitioners, pharmacists, default

Q6_ReQue:
Objective:  This chapter recreates the patient-provider interface and offers insights into provider attitudes and behavior and their justifications for these.

Q8_SampCom:
177 general practitioners; 24 pharmacists; 20 health workers; 44 medical officers

Q14_Desc:
The two major components of the provider study were the public health services and the private medical practitioners in rural and urban areas.  A pilot study of one third of randomly selected Primary Health Centers (PHC) in the district (22 out of 86) gave us a broad understanding of the functioning of the TB program.  For the main study, the respondents included medical officers (MO) of PHCs who are responsible for diagnosis and treatment of TB at the PHCs; pharmacists who are expected to maintain the records and prepare periodic reports; health workers (HW) who deal with case finding and case holding; and private general practitioners (GP) practicing in selected PHC areas and urban blocks.

Data on rural public health functionaries were collected from 24 PHCs.  Semi-structured questionnaires for MOs were left behind with them and collected after allowing them sufficient time to complete the questionnaire.  Semi-structured interview schedules were also used to interview 24 pharmacists and all available HWS—54 total—at the 24 PHCs.

Q15_Outc:
On average, the GPs interviewed by the authors had four patients with TB under treatment.  By their own admission, most of them had no idea about the National Tuberculosis Program since the training they had received about TB control in their undergraduate years was woefully inadequate.

Shunting of patients from one center to another, in the name of “referrals,” was a major feature of the public health services.  The easiest defense proffered by most functionaries for their non-performance was a lack of adequate supplies and support services.  So HWs referred patients to the PHCs, rural hospitals, or the DTC without collecting their sputa as was expected of them, while blaming the PHC for not sending the reports on time and lack of glass slides, sputum cups and spirit; the MOs preferred to send patients to the DTC for investigations so that the onus of starting treatment did not rest on them, explaining that it was easier to go to the DTC, which was centrally located.

The other major problem in the program was dumping almost all program responsibilities—from sputum collection to examination, drug distribution, maintenance of drug registers, and indenting and arranging for collecting drugs from the DTC, recognizing and taking appropriate defaulter retrieval and maintenance and preparing of records and reports—on the pharmacist, who receives no formal training.  The pharmacists lacked the necessary knowledge—most of them could not enumerate the correct method of sputum collection, their ideas of a defaulter were vague, and very few could list the common side effects of anti-TB drugs.

Q17_Conc:
There is little communication between the DTP and the private sector, and hence the private doctors are ignorant about the control measures they need to know or those available with the public health services.

The poor image that private doctors carry about the public health services and the lack of a proper referral system makes them reluctant to refer patients.

The stigma prevalent against the disease makes private doctors conceal the diagnosis of TB from their patients, leading to shopping for treatment by patients and poor treatment adherence.

Poor knowledge of the functionaries (especially the MO) combined with a strong belief in the SCC for all patients leads to drug shortages and manipulation of records.  

Poor understanding of the importance of case holding—inability to identify defaulters and enumerate recommended retrieval actions and badly maintained records—results in poor treatment adherence at PHCs.

The satisfaction of the State TB Officer with the performance of the program on paper in comparison to other states and contentment with the program outlay and expenditure has led to denial of programs at the ground level and a state of complacency.


Q1_Title:
Tuberculosis Management in Private Practice and Its Implications

Q1_Author:
Uplekar, M., Juvekar, S., Parande, S., Dalai, D., Khanvilkar, S., Vadair, A., & Rangan, S.

Q6_ReQue:
To understand the diagnostic and treatment practices about TB among private medical practitioners, and to determine the type and extent of interaction between the private doctors and public health functionaries working in TB control.

Q10_AduOth:
Doctors, pharmacists, and laboratory technicians

Q13_Comm:
Questionnaires analyzed using SPSS and EpiInfo – descriptive and categorical results presented. Group discussion was tape-recorded, transcribed, and edited.

Q14_Desc:
The study aimed to understand how TB patients are diagnosed and treated in private medical practitioner clinics. Private practitioners from urban and rural India were asked about their interactions with and perceptions regarding public health services available for TB control.

Q15_Outc:
All private medical practitioners reported that they manage TB patients in their clinics. Private providers relied on X-rays as most important diagnostic test. Most drug regimens reported by private medical practitioners did not conform to those recommended nationally or internationally. Ninety-nine percent of doctors reported that less than 50% of their TB patients completed treatment. In the group discussion, public health functionaries were aware of services provided under the National TB Program but private providers were not. There was a mutual distrust among the public health and private providers in terms of TB approach and perception to TB control, yet despite the differences in the groups maintained friendly relations with each other.

Q16_Limt:
Limitation of semi-structured questionnaire administered and obtained duly filled out in the presence of researchers was that while it provided a good insight into knowledge of the doctors, it could only be an indirect evidence of their actual practices of managing TB.

Q17_Conc:
Most national TB control programs are run through the public health services. In this study a significant number of TB patients receive treatment from private providers, which emphasizes the need to incorporate these providers in TB control efforts. Over dependence on chest X-rays and inappropriate use of drugs to treat TB have major implications in cost and drug resistance.

Q18_Recc:
Recommendations for collaborative efforts among public health and private providers by involving private providers in planning phases of TB and provide facilities for diagnosis, drug treatment, and measure to assure compliance with national program objectives.


Q1_Title:
Attention to gender issues in tuberculosis control

Q1_Author:
Uplekar, M., Rangan, S., Weiss, M., Ogden, J., Borgdorff, M., & Hudelson, P.

Q2_Key:
tuberculosis; gender; sex; access to care; research strategy

Q3b_Both:
This article reviews literature focusing on gender differentials, particularly factors that have different effects on the care seeking and treatment behavior for TB among men and women.  These factors, which can be considered both internal and external influences, include self-image, status in family and society, access to resources, and stigma.

Q6_ReQue:
This paper considers the role of gender at various steps in effective TB care.  A research strategy to study and account for gender differences in TB control is proposed.

Q14_Desc:
A review of literature and field visits undertaken to better understand the role of gender in TB control helped develop a framework that suggests a strategy for research to explain gender differentials in TB control.

Q15_Outc:
Health seeking and treatment behavior of men and women suffering from TB is largely determined by how he or she and those around perceive the symptoms, regard the diagnosis, accept the treatment, and stay with it.  Gender may influence each of these and affect detection of the disease and its outcome.  It is known that more men than women are diagnosed with TB and that among those who receive treatment, women generally tend to comply better and are less likely to die of the disease.

Q17_Conc:
A research strategy is necessary in order to study and consider the impact of gender on operational aspects of TB control, including improvement in the effectiveness of TB control programs.

Q18_Recc:
1) Re-examine age and sex-disaggregated data from past surveys and data maintained by TB programs to clarify the magnitude and nature of gender disparities.  Undertake new epidemiological surveys to establish a gold standard of sex ratio.

2) Develop a generic protocol incorporating appropriate epidemiological and social science methods to identify barriers and to confront gender-related problems of access to and care within TB programs.

3) Adapt the protocol for comparative study in multiple and diverse settings with a functioning TB program, willing program staff, and local research capacity.

4) Pilot proposed interventions for gender-sensitive TB control, and compare experiences in different settings.

5) Develop guidelines and tools for TB programs to minimize gender disparities.


Q1_Title:
Patient compliance with tuberculosis treatment in Ghana: factors influencing adherence to therapy in a rural service programme

Q1_Author:
Van der Werf, T., Dade, G., & Van der Mark, T.

Q6_ReQue:
Objective:  To study to nature, extent, and risk factors of default behavior and to evaluate the effect of health education at the chest clinic combined with home visits paid by liaison health workers in a rural African tuberculosis service program.

Q13_Comm:
Chi-square (x2) test or Fisher’s exact test if applicable were used.

Q14_Desc:
The purpose of this paper is to study the nature, extent, and risk factors of default behavior and to evaluate the effect of health education at the chest clinic combined with home visits paid by liaison health workers in a rural African tuberculosis service program.  The study was carried out in the Agogo Hospital in the Ashanti Region of Ghana.  During the study period, from October 1984 to July 1987, 569 patients had sputum-smear positive PTB.  Their records, updated by June 1988, were analyzed as the first part of the study.  For the second part of the study, data from questionnaires held among PTB patients in 1985 and 1987 were analyzed.

Q15_Outc:
The analysis of data of registered patients showed that male patients (n=371) had a significantly higher default rate (52.3% vs. 39.9%, p<0.01) and likewise significantly lower cure rate than female patients (n=198; 42.8% vs. 53%, p<0.025).  Longer home-to-clinic distances were significantly associated with higher default rates if the different regions of habitat were compared (p<0.0001).  In 1987, Illiterate patients did equally well in taking their drugs as instructed as those with some form of formal education (80% vs. 83%).  This was much better than in 1985, when only 43% did so as instructed.

The authors found no association between educational level and default from therapy, although knowledge of the disease was clearly better among educated patients.  In 1985, almost all defaulting patients reported financial barriers.  (Although the Agogo Hospital has been operating a poor and sick fund, travel expenses could not be reimbursed and this was often a greater financial burden than the hospital charge.)

Q17_Conc:
There was no evidence from the questionnaire that major changes had occurred in patients’ social lives after onset of their disease, and we do not think that PTB had a stigmatizing effect on our patient, resulting in default, but clearly the fear of contracting tuberculosis was the cause of non-cooperation among some liaison health workers.

Ghanaian PTB patients, probably not unlike other PTB patients in Africa and elsewhere, must have confidence in the doctors and the staff who run the tuberculosis program if they are to continue treatment at the expense of precious time and money, long after symptoms have subsided.

Q18_Recc:
Patient compliance can be enhanced by an understanding and sympathetic attitude from hospital staff.  It has been shown that patient compliance can be enhanced significantly in chronic conditions other than PTB (i.e., hypertension).  The authors strongly believe that commitment together with a willingness to cross cultural, religious, and language barriers can improve the generally poor results in tuberculosis service programs in rural Africa, where the reported percentage of patients lost to follow-up is over 65%.


Q1_Title:
Sociocultural Aspects of Tuberculosis Control in Ethiopia

Q2_Key:
TB, ethno-medical knowledge, compliance, sociocultural determinants

Q6_ReQue:
This article examines ethnomedical knowledge and practices related to TB conceptualization and management.

Q14_Desc:
An adult health status survey was administered to 217 in a rural southern Ethiopian community.  The main research objective was to study the sociocultural determinants of Sidama therapeutic behavior in a pluralistic medical setting.  In structured, open-ended interviews carried out with traditional medical specialists, patients, and other informants, prevailing illness causation theories, ethnophysiological concepts, and indigenous perspectives on TB were unraveled.  Management of predominant infectious diseases, including TB, through utilizations of traditional medicine was also investigated.  Ethnomedical practices, therapeutic techniques, and illness behavior were recorded through participant observation.

Q15_Outc:
The findings show that while symptomatological concepts coincide with biomedicine, the local etiological model postulates empirically based causational factors unrelated to TB.  Therapeutic preference hinge on the utilization of ethnobotanical remedies and their expected emetic effects.  The relevance of TB-related ethnomedical knowledge and management practices is discussed in relation to primary health care and disease control programs in Ethiopia.

Q16_Limt:
The difficult political situation in Ethiopia at the time of fieldwork made it unfeasible to conduct a large-scale rural survey using random sampling techniques.  Thus, while the limitations of the sample may preclude broad generalizations, the findings can be regarded as indicative of nosological and therapeutic patterns of TB management prevailing in the region.

Q17_Conc:
It is recommended that health education interventions, illustrating the nature and transmission avenues of TB and the effects of biomedical therapies, precede and/or accompany vaccinations campaigns or chemotherapy.  Teaching materials should valorize existing ethnomedical notions that emphasize contagion as an avenue of disease transmission, and the importance of nutritional adequacy in fighting the disease.

Q18_Recc:
Additional research is needed in order to identify the ethnomedical classification of other forms of TB and to determine where or not these are subsumed under separate syndromes or illness labels.


Q1_Title:
Directly observed therapy and treatment adherence

Q2_Key:
tuberculosis; DOT; directly observed therapy; adherence

Q3b_Both:
This article falls under both internal and external domains in that it focused on a review of published reports of direct observation therapy, with an emphasis on intervention studies that assessed the effects of DOT on patient adherence.  These interventions were then compared against elements of the World Health Organization’s DOT short-course strategy, including political commitment and a reporting system that documents the progress in curing the patient.

Q6_ReQue:
Published reports of direct observation therapy (DOT) programs were systematically identified and reviewed and compared with the five elements of the World Health Organization’s short-course DOT program.

Q14_Desc:
Published reports of direct observation therapy (DOT) programs (i.e., interventions that assessed the effects of DOT on patient adherence) were systematically identified, reviewed, and then compared with the five elements of the World Health Organization’s short-course DOT program, including political commitment; improved laboratory analysis; direct observation of patients swallowing each dose of medication; a drug supply that provides the correct complete short-course drug combination for free; and a reporting system that documents the progress in curing the patient.

Q15_Outc:
Of the 111 studies identified, 32 describing 30 programs or program clusters met the selection criteria.  Most of the studies were done in the US or South Africa, and the rest were from a variety of foreign countries.  The information that was extracted focused on interventions targeting patients, including incentives, sanctions, defaulter actions, and features designed to make programs acceptable and patient-centered; interventions targeting health-care providers; and external financial support.

Q16_Limt:
Most (23 of 32) of the studies covered fewer than 1000 people, so it may not be possible to replicate their results in national programs.

Q17_Conc:
DOT programs frequently consist of more than the five elements of WHO’S strategy, including incentives, tracing of defaulters, legal sanctions, patient-centered approaches, staff motivation, supervision, and additional external funds.  Focus on direct observation as a key factor in the promotion of adherence seems inappropriate.

Q18_Recc:
Multiple components might account for the success of DOT programs, and WHO should make these explicit.  The authors proposed that the WHO make their definition of DOT short-course more informative by adding the following component to improve adherence that include incentives, defaulter actions, and patient-centered design.  It has also been suggested that the WHO explicitly indicate that the improvement in programs that they propose in their DOTS strategy generally requires the additional resources from external funds or reallocation of existing resources.  The authors also caution against simplistic interpretation, of which particular factors account for success in operational programs.  Further trials are necessary to assess the efficacy of interventions incorporated in TB control programs.  Also, operational research will help to measure the performance and acceptability of these inputs in different settings.


Q1_Title:
Tuberculosis and AIDS: The Impact on the Hospital Social Worker

Q2_Key:
TB, AIDS, hospital social worker, safety

Q3b_Both:
The article addresses individual-level factors such as fear of exposure to TB/HIV (internal) and recommendations for policies to educate and protect hospital social workers that work with TB/HIV patients.

Q6_ReQue:
The article identified and clarified challenges that are exacerbated by the overlap of TB and AIDS; the impact on the worker’s personal safety, the impact on the therapeutic relationship, and provided action steps for workers facing these challenges.

Q10_AduOth:
article targets social workers & hospital social workers

Q14_Desc:
The article explored the following areas: 1) the historical context of TB/AIDS with a particular focus on the societal context; 2) the implications on the hospital social worker; 3) action steps to help prepare and support hospital social workers who are providing direct services to this patient population.

Q15_Outc:
Social workers working with patients over long periods of time in confined spaces can be at risk for contracting TB.  The therapeutic relationship is impacted by the barriers imposed by the nature of disease transmission and the isolation precautions necessary for protection.

Q17_Conc:
Since hospital social workers serve as liaisons between patients and providers, they need to understand the disease, the appropriate precautions and treatment regimes.  They need to help allay their own fears, and fears of others, to maintain appropriate standards of care.  The collaborative relationship with staff, and the facilitator role makes social workers an integral component to effective treatment planning and patient advocacy.  They must find ways of coping with their own emotional responses to the resurgence of TB and their own fear of exposure to avoid physical and emotional withdrawal from their HIV-infected patients.

Q18_Recc:
To respond appropriately, certain action steps can be implemented.  Hospital social workers can request in-service educational programs concerning TB.  In-service training for hospital social workers on AIDS, TB or Medicine Services should be modeled after nursing orientation and training and include handouts and free and regular testing for TB.  Hospital social workers may also want to request or initiate programs for communicating AIDS/TB policies, and precautions, and safety practices to patients, families, and other hospital employees, as well as external providers who work with these patients.  To attend to the impact of TB on the therapeutic relationship, educational material can be added that is interactive and focused on developing a relationship despite infection control measure (i.e., learning to talk through a mask).


Q1_Title:
Knowledge of disease and treatment among tuberculosis patients in Mwanza, Tanzania

Q6_ReQue:
Objective:  To determine patients’ general knowledge of tuberculosis and the management of the disease.

Q9_Other:
Interviews guided by structured questionnaires

Q13_Comm:
The level of statistical significance was set at 5%.

Q14_Desc:
The present study attempted to evaluate the knowledge of tuberculosis patients about their disease.  The results obtained provided information on the knowledge base and common misconceptions among tuberculosis patients. 

From May 7 to July 7, 1998, 296 pulmonary tuberculosis patients were consecutively interviewed.  Information was obtained from interviews using a structured questionnaire and data from patient records.  Patients were asked to respond to general knowledge questions about tuberculosis based on the Tanzanian NTP treatment guidelines for teaching tuberculosis patients.  The responses to the questionnaire were divided into two main groups:  1) general knowledge about tuberculosis, and 2) knowledge about the general management of the disease.

Q15_Outc:
Correct answers to five out of the seven questions asked was regarded as satisfactory knowledge, and only 30% of the study population demonstrated this level of understanding of the disease and its treatment.  Persons with information on TB prior to diagnosis and those with higher education were more likely to have satisfactory knowledge.  There was a negative correlation between the level of knowledge and a patient’s age (P=0.01).  Knowledge was not significantly affected by sex or area of residence.  The two most important sources of information about TB were health workers and former TB patients.

A closer examination of patients’ responses raises one paradoxical issue:  the discrepancy between the inadequate knowledge observed among TB patients in this study and the consistently favorable treatment outcomes (high cure rates and case detection rates) achieved in the same population.  The reasons for the gap between knowledge and actions are unclear.  Perhaps the positive attitude shown by patients in this study towards cure of the disease may have a strong influence on their actions, and lack of knowledge may have a negative impact on the other aspects of health seeking behavior for TB patients, such as choice of treatment, early reporting for treatment, and stigmatization of the disease.

Q16_Limt:
The results of this study should be interpreted with caution, as the questions asked were exclusively confined to the Tanzanian NTP guidelines for teaching tuberculosis patients.  In addition, patients were included in the study irrespective of the duration of their treatment, and only smear-positive tuberculosis patients who attended health facilities were interviewed.

Q17_Conc:
One of the most important findings in this study is the positive role played by former TB patients as a source of tuberculosis information.  The finding that former TB patients were as important as health workers in disseminating health information is important for two reasons.  First, it may suggest that patients have confidence in former tuberculosis patients and are willing to discuss their illness, which ma indicate a potential for including former tuberculosis patients in community-based tuberculosis treatment (DOT).  Secondly, it may reflect a deficit in the health workers or the system, and therefore a need to improve the education of tuberculosis patients.

Provision of specific health information has proved successful in health education campaigns.  The results of this study highlight the importance for the NTP to build on existing knowledge and dispel misconceptions among TB patients.  Dissemination of specific information to tuberculosis patients remains an important tool in tuberculosis control.


Q1_Title:
Patient and health care system delays in Queensland tuberculosis patients

Q1_Author:
Ward, J., Siskind, V., & Konstantinos, A.

Q2_Key:
TB, diagnostic delay, patient delay, risk factors

Q3b_Both:
Patient health seeking delay and health system delay are both discussed.

Q5_Other:
Longitudinal retrospective cohort design was implied but not stated.

Q6_ReQue:
The objective was to investigate patient and health care system delays in the diagnosis of active TB in Queensland.

Q8_SampCom:
758 subjects used in patient delay analysis; 779 subjects used in health care system delay analysis.

Q10_AduIntl:
Australian - indigenous and non-indigenous Australian born; low and high risk migrants (countries not specified)

Q10_ACIIntl:
Australian - indigenous and non-indigenous Australian born; low and high risk migrants (countries not specified)

Q14_Desc:
Analysis of data abstracted from the QTCC database and review of charts.  The QTCC database contains information of all cases of TB notified in Queensland form 1985 on.  Symptomatic patients with bacteriologically or histological proven TB were considered as a total group and a pulmonary smear positive (PSP) group.  The goal of the data abstraction was to find factors relating to both patient and health care system delays, but focuses on the latter as these are more amenable to targeted interventions.

Q15_Outc:
The median patent delays were 29 days (total group) and 30 days (PSP group).  The median health care system delays were 22 days (total group) and 11 days (PSP group).  There were significant trends towards increasing health care system delays with increasing age and longer residency of migrants in Australia.  Health care systems delays were significantly longer for females and those aged over 45.  Migrants from countries of high TB incidence and indigenous Australians had shorter health care system delays compared to non-indigenous Australians.  Common reasons for diagnostic delays of more than 90 days were failure to perform appropriate investigations and misdiagnosis of chest x-rays.

Q16_Limt:
There are several limitations to this study.  The accuracy of dates of symptom onset and first medical presentation may be questionable because symptoms are frequently nonspecific and insidious in onset and because patients themselves do not supply the information directly.  While the potential for data quality to be reduced in cases diagnosed prior to 1989 was considered, the ascertainment of data related to diagnostic delay was similar to that employed since 1989.  Another potential cause of bias is that, in selecting a particular cohort, individuals who have been seen by a medical practitioner but who have not yet been diagnosed will not be represented.  Their diagnostic delays are likely to be longer on average, but such cases are likely to be rare.

Q17_Conc:
In Queensland, longer health care delays occurred principally in older age groups, particularly non-indigenous Australian-born females, and in migrants with longer residence in Australia.  In a low prevalence setting diagnosis can be difficult, but it is important to maintain appropriate diagnostic awareness in health care professionals.  Such awareness should reduce diagnostic delays, which add to human suffering, even though their epidemiological impact may be minimal.  There should be a low threshold for obtaining chest x-rays and sputum samples in patients with persistent cough.

Q18_Recc:
The longer health care system delay for females, principally non-indigenous Australian born females aged over 45, was an interesting finding which warrants further investigation.


Q1_Journal:
Occupational Medicine: State of the Art Reviews

Q2_Key:
health education, occupational health, TB, health workers

Q6_ReQue:
A chapter based on the experience of Hunter College, the NY Committee for Occupational Safety and Community Health, and the New York State Public Employees Federation in developing TB education programs.

Q9_Other:
Based on experiences of developing a program

Q10_AduOth:
Any employees at risk for contracting TB

Q14_Desc:
This article reviews programs that educate workers about TB.

Q15_Outc:
(1) Education: The goal of workplace TB control program is to reduce occupational exposure to prevent workers from developing TB infection and disease. TB education should inform and motivate. A comprehensive education program is the key link between TB policy and implementation.
(2) Worker Involvement: Worker involvement should be integrated in every element of TB worksite prevention programs. Conducting needs assessment is critical – one suggestion is to conduct focus groups. 
(3) Who needs TB education: workers in different settings need to learn about TB but the government has defined places where this training is required: health care settings, correctional institutions, homeless shelters, long-term care facilities, and drug treatment centers. 
(4) Elements of TB training programs: basic elements should include: history and reemergence of TB; epidemiology; transmission of disease; diagnosis; medical surveillance and prophylaxis; treatment of TB; MDRTB; TB and HIV; and TB prevention.
(5) Training Methodology: training should emphasize knowledge and skills development (see Table page 868).
(6) Design training for specific workplaces: workers should be involved in development of training, and the curriculum should be tailored to specifics at the workplace.
(7) Obstacles to TB education: engineering controls; regulations; prejudice; racist; workplace safety; resources; importance of TB education; lack of employee involvement.

Q17_Conc:
Resources for education are listed on page 691 and a case study of a model program is described in detail on page 689.


Q1_Title:
Knowledge and attitudes about tuberculosis of black hospitalized patients

Q6_ReQue:
The major aim of the present study was to ascertain whether recognition of disease and perceptions of danger were useful for understanding the perspective of the TB patient.

Q14_Desc:
A sample of 201 adult Black hospital inpatients with TB were interviewed to ascertain their knowledge and attitudes about the disease.  A structured questionnaire was designed to measure: 1) demographic characteristics; and 2) familiarity of TB signs and symptoms, perceptions of the frequency of the disease, predictability of the disease outcome and the degree of personal threat it poses.

Q15_Outc:
The major signs and symptoms were cough by 89%, loss of appetite by 67% and night sweats by 62%.  Although 87% thought that TB affected many people, it was rarely discussed; they considered their families were not at risk; it was easy to prevent, there was complete recovery after treatment and it was an acceptable disease to family and friends.

Q17_Conc:
Overall responses suggested that TB patients recognize their disease, expected a predictable outcome and did not feel threatened by it.  It would appear that Mechanic’s concept of illness behavior can be useful in understanding the attitudes of TB patients.  It was concluded that denial of personal involvement and a positive attitude towards cure and prevention may be factors that allow TB patients to cope with their disease.


Q1_Title:
Knowledge, beliefs, and feelings about tuberculosis

Q2_Key:
TB, Illness Behavior, Social Stigma, Affect, Health Behavior, Knowledge

Q6_ReQue:
1. Ascertain baseline information on knowledge, beliefs, and feelings about TB
 2. Evaluate the usefulness of the concept of “illness behavior” and social stigma

Q8_SampCom:
211 black, urban-dwelling, South Africans (100 Men, 111 Women) who attended a Comm. Health clinic.

Q13_Comm:
basic correlational and non-parametric tests performed.  Some differences were statistically significant.

Q14_Desc:
Article reports on an exploratory study using structured questionnaire-based interviews to assess tuberculosis-related knowledge, beliefs, and feelings.  The questionnaire measures knowledge, (via items about symptoms, causes of TB, etc.) beliefs, (via items regarding “typical health practices” and opinions about TB’s cure rate and course of treatment) and feelings (via items regarding threat/loss and social stigma).  This questionnaire was administered to a convenience sample of patients at an STD clinic and a general health clinic in urban S. Africa.

Q15_Outc:
Knowledge:  In general participants were minimally knowledgeable about TB, but many were able to correctly identify some symptoms and causes.  Composite knowledge scores were significantly different based only on educational attainment.
Beliefs:  In general, most participants believed TB could be cured and had accurate perceptions of the length of treatment.  Opinions were divided on whether people with TB should be isolated, with 58% of women and 35% of men supporting the practice.
Feelings:  Few thought that TB “always causes death” but most thought it “always causes pain”.  Men were significantly more likely to feel “threatened by TB” than women.  People with TB were thought of as “dirty"  by 60%), “eating bad food”(75%), “ordinary people” (23%), and “acceptable” (by 67% of respondents).  People with family history of TB attached less stigma to TB.

Q17_Conc:
Results show “minimal TB knowledge, misconceptions on hospitalization, treatment time, and isolation…” Also show “denial of risk, the threatening nature of the disease, and the association between bad food, dirt, and TB.”


Q1_Title:
Cognitive and affective reactions of black urban South African towards tuberculosis

Q3b_Both:
Article assesses cognitive/affective reactions towards TB, which included perceptions, social stigma, and poverty.

Q6_ReQue:
To ascertain cognitive and affective reactions towards TB, and to determine social influence impediments to voluntary presentation and case-holding.

Q7_TheoBas:
Angel and Thoits’ model concerning the cognitive structure of illness, in an attempt to ascertain the underlying dimensions that are used when people react cognitively and emotionally to TB. Specifically, concepts of perceived prevalence, perceived seriousness, and social desirability are used.

Q10_AduIntl:
Black and coloured communities in South Africa

Q10_ACIIntl:
Black and coloured communities in South Africa

Q11_Intl:
South Africa:  Transvaal, Daveyton, and KwaThema)

Q13_Comm:
95% confidence intervals, mean scores, standard deviations (SD), and probability levels are reported. Principal component factor analysis.

Q14_Desc:
A research study to identify the cognitive and affective reactions towards TB, and to determine if these affect voluntary TB presentation and case-holding. The research was conducted among South African Blacks from two urban townships, and included both TB patients and non-TB community members. Study participants were interviewed by trained personnel and completed a questionnaire designed to obtain information on background details, perceptions of TB, and a 19-item cognitive/affective scale (perceived prevalence, seriousness, and social stigma).

Q15_Outc:
The majority of patients were aware of the infectious nature of TB, that it could be cured and the length of the treatment. The most problematic issues were isolation for TB sufferers and the harm TB sufferers do to others. Cognitive/affective reactions were similar for TB patients and community members. Ten items from the 19 item scale resulted in 3 factors: (1) personal high threat and social rejection, (2) social stigma with emphasis on dirt, poverty, and poor nutrition, and (3) rejection of alcohol and tobacco consumption as causal agents of TB.

Q17_Conc:
On perceptions of TB, respondents knew about the infectious nature of the disease, that it was curable, the length of treatment and actions to take for prevention. The predominant cognitive/affective reactions towards TB were personal threat, social rejection and social stigma, providing support for the hypothesis. TB is still associated with dirt, poverty, and poor nutrition. The powerful force of social rejection and social stigma cannot be underestimated.

Q18_Recc:
Urgent need to address the impediments of social rejection and social stigma, in order to enhance case-finding and case-holding activities. TB control programmes need to place special emphasis on social support as a contributory factor in the reduction of the disease.


Q1_Title:
Supervised out-patient treatment of tuberculosis:  evaluation of a South African rural programme.

Q1_Author:
Westaway, M.S., Conradie, P.W., & Remmers, L.

Q2_Key:
South Africa, outpatient, defaulted, community involvement, volunteer health worker

Q6_ReQue:
Objective:  To evaluate the effects of a three-year out-patient treatment program in rural South Africa

Q14_Desc:
A supervised outpatient treatment program was initiated in a rural area of KwaZulu, South Africa, in 1987.  All newly diagnosed tuberculosis patients were admitted to the hospital for initial treatment.  Under the outpatient treatment program, patients were discharged as soon as they were well enough to continue supervised outpatient treatment at home, school, work, or the nearest clinic.  A patient who received more than 80% of the treatment required by the Department of National Health and Population Development was regarded as being successfully treatment.

On discharge from the hospital, patients were taken home by a nurse or the health adviser and introduced to their supervisor.  The nurse or health advisor visited all supervisors once a month to deliver the patient’s tablets and to ascertain whether there had been any problems with treatment.  If there had been problems, the patient was fetched from home, taken back to the hospital, and re-admitted to the TB ward.

Q15_Outc:
Analysis of treatment outcomes showed that in 1987,  88% of patients completed treatment, 8.5% defaulted, and 3.4% died.  In 1988, 93% completed treatment, 4% defaulted, and 3% died.  In 1989, 94% completed treatment, 3% defaulted, and 3% died.  Voluntary Health Workers supervised a majority of patients (68% in 1987, 82% in 1988, and 1989).  Only four patients were re-admitted to the hospital due to an unreliable health worker in this three-year period.

Q17_Conc:
The increase in numbers of patients who were supervised by a Voluntary Health Worker showed a high level of community involvement and participation, despite the lack of political change during this period.  This supervised outpatient treatment program has led to less disruption in the lives of TB patients and their families, a high level of compliance with treatment, and concerned community involvement and participation.


Q1_Title:
Tuberculosis: A Health Education Imperative Returns

Q1_Author:
White, G., Henthorne, B., Barnes, S., & Segarra, J.

Q2_Key:
TB, health education, health belief model, compliance

Q3b_Both:
Internal influences were discussed, such as those that comprise the health belief model.  External influences were discussed, such as TB laws and guidelines, the past health education movement and related tuberculosis education efforts.

Q4_Other:
retrospective review and recommendations for health education

Q6_ReQue:
To provide a basis for health education recommendations, the article reviews the factors contributing to the resurgence of tuberculosis, the nature of the current epidemic, and past health education efforts.

Q7_TheoBas:
An expanded health belief model is provided.

Q14_Desc:
To provide a basis for health education recommendations, the article reviews the factors contributing to the resurgence of tuberculosis, the nature of the current epidemic, and past health education efforts.  An expanded health belief model is offered as a foundation to guide educational campaigns.

Q15_Outc:
In combining the health belief model with the 3 levels of prevention, a broader foundation for planning education efforts emerges.  The expanded model can be applied on a collective basis as well as within individualized health education, as detailed in the authors’ model for tuberculosis prevention targeting individuals (table 1) or targeting corporations (table 2). This expanded health belief model addresses the level of prevention, susceptibility, degree of impact, and action.

Q16_Limt:
It is beyond the scope of this review to examine all historical aspects of the tuberculosis challenge, yet it was a massive collaborative effort between researchers, physicians, community volunteers, industry, government health officials and voluntary agencies that was responsible for the containment and reduction of tuberculosis contagion.

Q17_Conc:
Support of tuberculosis control will not evolve unless the threat and potential negative impact is perceived and acted upon.  This is true regardless of the nature of the target market, whether the general public, health care professionals or corporate executives.  The expanded health belief model provides a structure for initiating and maintaining a comprehensive health education campaign to control TB.

Q18_Recc:
Recommendations for health education initiatives are as follows:  public information programs are needed to alert a public that grew apathetic about tuberculosis as its incidence declined over a 30 year period; school health education and community health education programs should be well conceived & distinguishable from public information programs; patient education programs must address difficulties encountered in compliance with long term prescriptives; planning, development and implementing screening programs at the local level should be a joint effort coordinated with the local health department, public and private community organizations and health care providers in the community.


Q1_Title:
Strategies for Effective Education in a Jail Setting: The Tuberculosis Prevention Project

Q1_Author:
White, M., Duong, T., Cruz, E., Rodas, A., McCall, C., Menendez, E., Carmody, E., & Tulsky, J.

Q2_Key:
TB, intervention, prisons, inmates, correctional healthcare, health education

Q4_Other:
Educational session /strategies for working in a jail

Q6_ReQue:
The purpose of this article are to (a) describe the educational process provided to inmates in jail, including developing the educational protocol and hiring and training of staff members and (b) describe the applications of an educational intervention in a jail setting.

Q9_Other:
Interaction and feedback of staff/educators through weekly group meetings

Q14_Desc:
This article describes the educational sessions and illustrates some of the barriers to working in a jail setting and strategies to overcome them.  The nature of jail itself, inmate characteristics, the characteristics of educators, and the educational sessions themselves interacted in different ways to enhance or impair the interaction.

Q15_Outc:
Strategies for providing education in a jail setting include: gaining safe access to the jail; developing the protocol specific to the jail population; hiring staff members sensitive to the incarcerated population; Educator training and educational setting specific to the group under study.  Intervention applications included: characteristics of the jail, the inmates, the educators, and the educational sessions that enhances or impeded the ability to work in this unique setting.

Q17_Conc:
The jail setting provides unique challenges to educators.  Because health is not the primary focus of jail, persons providing information and counseling to inmates must do so within the formal rules and informal customs of this system.  The hiring of staff members outside of the jail system who were ethnographically appropriate contributed to its successes.  The methodical training of each educator was also essential.  Finally, the combined support of the jail staff members was integral to the project.


Q1_Title:
Randomized controlled trial of interventions to improve follow-up for latent tuberculosis infection after release from jail

Q1_Author:
White, M., Tulsky, J., Goldenson, J., Portillo, C., Kawamura, M., & Menendez, E.

Q2_Key:
TB, randomized controlled trial, intervention, prisons, inmates

Q6_ReQue:
The aim of the study was to assess two interventions given to inmates (education or the promise of an incentive) improved adherence (measured as (1) first visit to the TB clinic within 1 month of release and (2) completion of a full course of therapy.

Q8_SampCom:
558 inmates enrolled and randomized:  325 were released and assigned as follows: Education (n = 107); Incentive (n = 114); Control (n = 104)

Q10_AduFrBrn:
foreign born were included, country of origin not stated

Q14_Desc:
A randomized controlled trial was conducted at San Francisco City and County Jail.  Subjects undergoing therapy for LTBI who spoke English or Spanish were randomly allocated to receive education every two weeks while in jail; an incentive if they went to the SF county TB clinic within 1 month of release; or usual care.  The main outcome measures were completion of a visit to the TB clinic within 1 month of release and completion of therapy.

Q15_Outc:
Of 558 inmates enrolled, 325 were released before completion of therapy.  Subjects in either intervention group were significantly more likely to complete a first visit than were control subjects (education group, 37%; incentive group, 37%; and controls, 24%) (adjusted odds ratio based on pooled results for the education and incentive groups, 1.85, CI 1.04-3.28; P=.02).  Those in the education group were twice as likely to complete therapy compared with controls (adjusted odds ratio, 2.2, CI 1.04-4.72; P=.04).  Of those who went to the TB clinic after release, subjects in the education group were more likely to complete therapy (education group, 65%[24/37]; incentive group, 33% [14/42]; and control group, 48% [12/25]; P =.02).

Q16_Limt:
Limitations to the study included selection of English- or Spanish-speaking inmates, to the exclusion of inmates who were non-English speaking Asian/Pacific Islanders.

Q17_Conc:
Education or the promise of an incentive improved initial follow-up.  Education was superior to an incentive for the completion of therapy.  Fairly modest strategies provided in jail can improve adherence.  Further links between jail health services and community care should be explored.

Q18_Recc:
Further work should focus on the role of postrelease reinforcement, based on our anecdotal observation of a follow up effect among nonadherent subjects.  Foreign born subjects in the US for 5 years or less, identified as being at the highest risk for disease progression, were only one-third as likely to go to the clinic after release, but were just as likely to finish medication if they made the postrelease visit to the TB clinic.  This warrants further study to determine if those who are least acculturated are initially lost to the system, but once engaged in care, follow through to completion.


Q1_Title:
Coping with Africa's increasing tuberculosis burden:  are community supervisors an essential component of the DOT strategy?

Q6_ReQue:
Article reports on the successful use of voluntary lay people and community health workers in the delivery of community-based DOT.

Q11_Intl:
South Africa: KwaZulu/Natal (Hlabisa District)

Q13_Comm:
Chi-square test with p values < 0.05 as statistically significant.

Q14_Desc:
Tuberculosis incidence in Africa is increasing dramatically and fragile health systems are struggling to cope. Potential coping capacity may lie within affected communities but this capacity needs to be harnessed if tuberculosis is to be controlled. Since 1991 all patients with tuberculosis in Hlabisa health district, South Africa have been eligible for community-based directly observed therapy (DOT). Patients are supervised either by a health worker (HW) in a village clinic, or in the community by a community health worker (CHW) or a volunteer lay person (VLP).

Q15_Outc:
Tuberculosis incidence increased from 312 cases in 1991 to 1250 cases in 1996. By December 1995, 2622 (87%) of 3006 patients had received DOT, supervised mainly by VLP (56%) but also by HW (28%) and CHW (16%). The proportion supervised by HW fell from 46% in 1991 to 26% in 1995 (P < 0.0001). More patients supervised by VLP (85%) and CHW (88%) than by HW (79%, P = 0.0008) completed treatment. Case-holding by HW declined more between 1991 and 1995 (84% to 71%, P = 0.02) than did case-holding by both CHW (95% to 90%. P = 0.7) and VLP (88% to 84%, P = 0.4). Mortality was similar (4-6%) and stable over time, irrespective of the supervisor.

Q17_Conc:
High tuberculosis treatment completion rates are achievable and sustainable for several years in resource-poor settings despite a massively increased case load if community resources are harnessed. Patients may be more effectively supervised by voluntary lay people than by health workers under these circumstances, without being placed at increased risk.

Q18_Recc:
These findings suggest that community supervisors may be an essential component of any DOT strategy.


Q1_Title:
Traditional healers as tuberculosis treatment supervisors: precedent and potential

Q1_Author:
Wilkinson, D., Gcabashe, L., & Lurie, M.

Q2_Key:
South Africa, traditional healers, community care

Q6_ReQue:
Objective:  To determine precedent and potential for traditional healers to act as tuberculosis treatment supervisors.

Q14_Desc:
In South Africa, many traditional healers are members of well-organized national organizations that are seeking formal recognition from government.  With this in mind, the authors of this article studied the potential role for collaboration between the health services arena and traditional healers, especially as TB treatment supervisors.  The authors sought to examine what precedent and potential exists for traditional healers to act in this role. 

The authors’ study took place over a nine-month period, beginning in February 1998.  First, the authors undertook a literature review to discern any precedent for the involvement of traditional healers in TB treatment supervision.  Then, they interviewed 100 TB patients to determine the current use of healers in the community, and inquire about patients’ willingness to use healers as formal supervisors.  Finally, the authors interviewed 24 healers in the project sub-district to estimate the willingness of healers to act as supervisors.

Q15_Outc:
Despite extensive literature on the interaction between traditional healers and conventional health services, including descriptions of traditional understandings of TB, the authors were unable to identify any published work that reported supervision of TB patients by traditional healers.  Of 100 patients interviewed, only 10% had used a healer as the first health provider for their illness, but 40% had attended a healer at some time prior to diagnosis.  Although only 4% believed healers could cure TB, 84% would consider choosing a healer as a treatment supervisor.  Of the 24 healers, 15 (63%) distinguished between two types of diagnoses made among patients with symptoms suggestive of TB:  TB and idliso.  Idliso, according to the healers, is poisoning or bewitching, and is said to be best cured by healers, while TB is infectious and cannot be cured by healers.  Most healers (88%) reported having referred patients with possible TB to the hospital in the past; all were keen to negotiate collaboration with health services, and 92% were willing to act as treatment supervisors.

Q17_Conc:
The apparent potential for collaboration between traditional healers and conventional services now needs to be formally and carefully tested.  In the authors’ project sub-district, interested traditional healers will be made available as TB treatment supervisors, along with clinic nurses, community health workers, and volunteers.  The proportion of patients from the areas that decide to accept a healer as supervisor will be documented, and treatment progress will be monitored.  In addition, a network will be developed within the area whereby patients with symptoms suggestive of TB who attend healers can have access to sputum microscopy without formal referral to a hospital.  Furthermore, the critical relationship between traditional healers and conventional health workers will need careful study.

Q18_Recc:
It seems that there is a substantial history of distrust between healers and doctors, but it is also likely that a more modern approach, that is mutually respectful, offers substantial scope for collaboration.  Critical issues including, among others, the level of financial reward for services rendered, audit of practice, quality control and safety will need careful consideration.  If other treatment supervisors are not paid to supervise, should healers be paid anyway?  Current supervisors in Hlabisa seem not to abuse the drugs they keep, but is this also likely to be true of healers?  Clinic nurses, community health workers and, up to a point, volunteers are clearly accountable to the health service, but as independent practitioners, the same is unlikely ever to be true for traditional healers.  Does this matter?  These questions will need to be addressed in projects that study the work of traditional healers in TB management and control.


Q1_Title:
Practical skills and valued community outcomes: the next step in community-based education

Q1_Author:
Williams, R., Reid, S., Myeni, C., Pitt, L., & Solarsh, G.

Q2_Key:
community health services; education, medical, undergraduate; programme evaluation; South Africa; treatment outcome; tuberculosis, therapy

Q6_ReQue:
The purpose is to describe a unique response to all three community-based education goals: (1) expose students to community resources related to health care; (2) broaden students’ perspectives by familiarizing them with family and community context of health care; and (3)give students feasible skills they can use later while in busy clinical practice.

Q7_TheoBas:
Community orientated primary care (COPC) model was used to link the individual patients and the broader community perspective – COPC is a process for joining public health and primary care.

Q8_SampCom:
114 senior students (41 teams and 5 study groups); 41 TB patients

Q11_Intl:
South Africa: Durban: University of Natal

Q13_Comm:
Comparisons of means using two-tailed t-tests, alpha value of 0.01 was used to avoid Type 1 error because of the multiple comparisons tested.

Q14_Desc:
Community-based medical education (CBE) has clear value. However, there are aspects of CBE where improvement is possible. First, communities do not generally receive valued outcomes in exchange for participation in the CBE process. Secondly, students are usually not trained to influence health in the community using methods that are realistic in busy clinical practice. A CBE rotation was designed to address these problems. Rotation activities were structured to facilitate development of a health programme desired by the community while giving students practical skills for later use. Working with community residents and health staff, sequential groups of students carried out, in turn, problem analysis, resource identification, planning and implementation activities aimed at establishing a community tuberculosis (TB) control programme.

Q15_Outc:
At the end of the academic year, the TB control programme was approximately 60% in place, and 90% of TB patients cared for by the students were completing treatment. Overall, students rated the experience good for learning about health care in community settings and about methods for community health programme development. Student ratings were significantly higher for those groups whose activities brought them into greater contact with community residents. Qualitative data from students revealed that students enjoyed most of the home visits and their work with community members.

Q16_Limt:
The ‘real-time’ nature of the medical rotation planning created logistical problems. The environment in which the rotation operated also created some problems as some students started the rotation immediately after placements are rural hospitals. A political debate in South Africa (focusing on mandatory community medical service) at the time of 7-month education period may also have negatively affected students’ reception to the project. Finally, due to the sequential structure of the rotation, none of the students received full breadth training of community oriented primary care (COPC) skills.

Q17_Conc:
The `real-time' nature of planning the sequential student groups' work created logistical problems and, as an isolated activity, the rotation had little impact on student attitudes toward community-based careers. Expanding the goals for CBE is both feasible and important. Further work should focus on refining designs for this next step in CBE.


Q1_Title:
Tuberculosis Knowledge among New York City Injection Drug Users

Q1_Author:
Wolfe, H., Marmor, M., Maslansky, R., Nichols, S., Simberkoff, M., Des Jarlais, D., & Moss, A.

Q2_Key:
Injection drug users, knowledge, New York City

Q6_ReQue:
Objective:  To assess tuberculosis-related knowledge among New York City injection drug users.

Q14_Desc:
The authors administered structured interviews measuring tuberculosis knowledge to 494 New York City injection drug users, 31% of whom reported a history of having a reactive tuberculin skin test.  The survey was conducted between November 1992 and February 1993 as part of a cohort study of HIV infection among IV drug users.  Subjects were asked items developed for the 1994 AIDS Knowledge and Attitudes Supplement to the CDC National Health Interview Survey measuring transmission knowledge.  They were also presented with ten agree/disagree statements that were developed to assess their knowledge of the difference between a reactive skin test and active tuberculosis, the importance of medication adherence, and perceived seriousness and pathogenesis of TB.

Q15_Outc:
One fourth of the subjects understood the distinction between infection and active disease, but subjects reporting a history of a reactive skin test were more than twice as likely (40% vs. 18%, P<0.0001) to respond correctly to all three relevant items.  In a multivariate analysis controlling for sex, race, age, and education, the strongest predictor of infection versus disease knowledge was self-reported skin test status

Hispanic subjects were less aware of the importance of medication adherence than non-Hispanics (52% vs. 74%, P<0.05), as were subjects under age 35 compared with those over age 35 (49% vs. 64%, P<0.01).  

The following variables—sex, crack use, living situation, education, and HIV status—were not significantly associated with any of the areas of knowledge measured.  The independent association between subjects’ skin test positivity and their knowledge of the difference between infection and disease most likely reflected education they received during the administration and reading of their tuberculosis skin tests.  Subjects with a history of skin test reactivity, however, did not know any more about medication adherence or transmission than other subjects, suggesting the need for more complete education.

Q17_Conc:
Injection drug users are the population most likely to be dually infected with tuberculosis and HIV.  Drug treatment programs are often their primary source of contact with the health care system.  As this survey demonstrates, tuberculosis prevention and education, like HIV efforts, must be integrated into drug treatment programs.

Q18_Recc:
Some of the misconceptions revealed in this survey may stem from the overgeneralization of knowledge about HIV:  the assumption that all persons with a reactive skin test can transmit the disease to others and will invariably develop active tuberculosis, and the belief in sexual transmission of tuberculosis.  Effective education in populations knowledgeable about HIV must highlight the differences between the two diseases.

Also, the high level of the perceived stigma of tuberculosis, in conjunction with misinformation regarding transmission and disease, is likely to harm screening efforts and medication adherence.  Thus, education about tuberculosis is urgently need if such containment campaigns are to succeed.


Q1_Title:
Attitudes Regarding Tuberculosis in Immigrants from the Philippines to the United States

Q1_Author:
Yamada, S., Caballero, J., Matsunaga, D., Agustin, G., & Magana, M.

Q6_ReQue:
This paper explores Filipino knowledge, attitudes, and practices concerning TB.

Q8_SampCom:
4 focus groups with a total of 36 participants

Q14_Desc:
The research reported in this article examines the knowledge, attitudes, and practices related to TB among Filipino immigrants through the use of focus groups.

Q15_Outc:
Comments and beliefs from the focus group participants shared several themes.  These themes related to causation and mechanism of TB, social and psychological implications of TB, and treatment of TB.  Theories by Filipino focus group participants of the causes of TB include 1) natural forces/environmental exposures, 2) imbalances of the body, and 3) contagion.  Ideas about treatment include 1) modern medical attention, 2) traditional medicine, 3) changes in the environment and exposures, and 4) correcting imbalances of the body.

Q16_Limt:
Focus group participants were not randomly selected to represent Filipinos in the US, so the attitudes that they expressed cannot be generalized to Filipinos who are acculturated to different degrees.  Also, individual focus group members held divergent opinions; all of which could not be incorporated into the report.  Finally, biases could have occurred due to the fact that some individuals who conducted the focus groups were involved in the interpretation of the results.

Q17_Conc:
The researchers sought to delineate common attitudes regarding TB among Filipino immigrants and thereby seek to improve the cultural competence of those providing TB services for them.

Q18_Recc:
Implications for practitioners: Increase awareness of common cultural attitudes which could build bridges of understanding between patient and practitioner and enhance the effectiveness of the clinical encounter.  Also, strengthening the partnership between the primary care system and TB control services may allow for improved identification and treatment of TB.  Practitioners who care for Filipino patients with TB may also need to focus patient education around the degree of transmissibility of TB and the manner in which it may be reduced.

Implications for educators: Educators should examine their own attitudes, ideas, and beliefs they carry during certain encounters with patients with certain diseases.

Also, community-based educational interventions among Filipino immigrants about the true degree of transmissibility of TB may lead to less stigmatization and, consequently, to less hiding of illness.  Addressing fears surrounding immigration may also ensure cooperation and adherence to therapy.


Q1_Title:
Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal

Q1_Author:
Yamasaki-Nakagawa, M., Ozasa, K., Yamada, N., Osuga, K., Shimouchi, A., Ishikawa, N., Bam, D., & Mori, T.

Q2_Key:
Gender, delay, TB, traditional healer, health care-seeking behavior

Q3b_Both:
Gender and beliefs affect what type of provider is visited, and the mean time for TB diagnosis.

Q6_ReQue:
To examine delays in tuberculosis (TB) diagnosis and compare health care seeking behaviour between men and women in Nepal.

Q13_Comm:
Mann Whitney non-parametric test or the Kruskal-Wallis test, Chi-square test, logistic regression, p value < 0.05 was considered statistically significant.

Q14_Desc:
Directly observed treatment for tuberculosis using a short-course regimen (DOTS) was introduced in a rural area of Nepal. All new patients assigned to DOTS from mid-December 1997 to mid-June 1999 were eligible for the study. A cross-sectional analysis of patient interviews.

Q15_Outc:
Women were found to have a significantly longer total delay before diagnosis of tuberculosis (median 2.3 months for men, 3.3 months for women). When they visited traditional healers first, women had a significantly longer delay than men from the first visit to health care providers to diagnosis (median 1.5 months for men, 3.0 months for women). More women (35%) visited traditional healers before diagnosis than men (18%), and were more likely to receive more complicated charms from traditional healers. Men tended to visit the government medical establishment first if they knew that free TB treatment was available, but women did not.

Q16_Limt:
More women than men died of defaulted soon after starting treatment. Those patients not interviewed (due to death) may therefore have had a longer delay in case detection than those included in this study.

Q17_Conc:
Women were more likely to visit and to believe in traditional healers; this might lead to the longer delays experienced before TB diagnosis. Women visited the distant government medical facilities less often even if they knew free TB treatment was available there.

Q18_Recc:
An effective delay among means of shortening the delay among women is thought to be to develop suitable links between modern and traditional health services.


Q1_Title:
Strategies for Suppression, Containment, and Eradication of Resurgent Tuberculosis

Q1_Author:
Young, R., Rachal, R., Bailey, S., Tate, H., & Nelson-Knuckles, B.

Q2_Key:
TB, diagnosis, drug therapy, epidemiology, multidrug resistant, prevention and control, transmission, tuberculin test

Q6_ReQue:
This review provides strategies for the suppression, containment, and eventual eradication of resurgent tuberculosis.

Q7_TheoBas:
Article includes a model of multiple risk factors for TB.

Q14_Desc:
The objective of this paper is to provide strategies for suppression, containment, and the eventual eradication of this resurgent TB epidemic proposed through socioeconomic stability, public health policy measures for communities and health care organizations, and guidelines for health care providers.

Q17_Conc:
Socioeconomic status rather than genetic constitution appears to be the major factor responsible for unfavorable incidence, prevalence, and mortality data on TB among minorities.  Thus, TB is the medical expression of socioeconomic ills.  Suppression and containment of resurgent tuberculosis are being regained through improved health care guidelines and policy measures that direct attention to rebuilding the infrastructure of our public health system.  Having gained the initiative, the effort must continue.

Q18_Recc:
A successful strategy for  TB eradication is multifaceted and central to a vertically integrated system from federal, state, and county public health departments and closely tied to hospitals, neighborhood health clinics, HMOs and individual providers’ offices.  It is also horizontally integrated into government legislation to provide health insurance coverage for 38 million uninsured Americans. Simultaneous integration of health care into the welfare system must be accomplished.  Widespread use of new diagnostic technologies and the development of more effective therapies are required.  Continued emphasis on the developing longer acting anti-tuberculous drugs by the pharmaceutical industry with wider spacing of the dosing interval will be expected to enhance compliance through the simplification of DOPT and DOT.  

Other socioeconomic initiatives with political overtones are preventing HIV/AIDS, reducing unemployment and homelessness, crime prevention, and decreased overcrowding of the penal system.  Heightened initiatives of the enforcement on illegal immigration are laudatory, as is the continued war on substance abuse at all levels.  Increased funding for migrant health care, with vigorous enforcement of existing laws and regulations pertaining to labor contractors are recommended.


Q1_Title:
Long-term Risk of Tuberculosis Among Foreign-born Persons in the United States

Q1_Author:
Zuber, P., McKenna, M., Binkin, N., Onorato, I., & Castro, K.

Q6_ReQue:
To describe the risk of TB among foreign-born persons with respect to their length of residence in the United States.

Q8_SampCom:
Sample size (N)=   The study used a referent group of 160,839 TB-diagnosed persons from Census data between 1986-1994) and examined the country of origin and other characteristics of the 55,387 foreign-born individuals in that group..

Q10_AduFrBrn:
The specific foreign-born groups were not specified.

Q13_Comm:
Incidence and relative risk estimates were calculated for foreign-born members of the census sample.

Q14_Desc:
Using the database of all verified TB cases reported to CDC between 1986-1994, researchers examined characteristics such as country of origin, length of time in United States, age at immigration, etc to determine long term risk of TB incidence.

Q15_Outc:
The overall total case rate for foreign born persons during this period was 33.1 per 100,000 (compared to 7.8 per 100,000 for US born individuals).  Patients from Mexico, Philippines, Vietnam, Korea, China, and Haiti accounted for 63.7% of all foreign born cases, with Vietnam, Philippines, and Haiti with the highest rates among them.

In terms of arrival age and length of stay in US, individuals who arrived in the US after their fifth birthday had incidence rates 2-6 times higher than individuals who arrived prior to age 5, indicating an effect for age at immigration. Case rates do not differ vastly between individuals based on duration of presence in the United States.

Q17_Conc:
The increase in foreign born TB incidence between 1986-1994 was not limited to new arrivals, in cases among long-term residents “has paralleled that observed among recent arrivals.” 
Two main points were highlighted.  One, TB incidence is high among FB persons from areas with high prevalence…even several years after coming to the United States.  Second, the longer individuals live overseas before coming to the US, the greater their long-term risk of TB incidence.

Q18_Recc:
Must identify and treat active disease among new arrivals.  Data supports overseas testing of immigrants and also suggests a need for reevaluation and prophylactic treatment among foreign-born individuals with LTBI once they enter the US.


Q1_Title:
Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis

Q1_Author:
Zwarenstein, M., Schoeman, J., Vundule, C., Lombard, C., & Tatley, M.

Q3b_Both:
Study looked at patient adherence, comparing DOT to self-administered therapy, while also considering the clinic management and health care staff’s relationships with patients.

Q6_ReQue:
When comparing directly observed treatment with self supervision, how effective was each approach in terms of successful completion of TB treatment.

Q8_SampCom:
Analysis was completed on 216 participants from two sites

Q13_Comm:
Original sample sizes were planned to detect a 20% difference in outcomes between the groups at each site, with a power of 80% at a significance level of 5%.

Q14_Desc:
The authors compared treatment at two sites between patients randomly assigned to either directly observed treatment, or self supervision, to asses the effectiveness of each on completion of TB treatment. The authors state they believe this is the first ever randomized controlled trial of this nature.

Q15_Outc:
Treatment completion rates were essentially equivalent between self-supervised patients and those on directly observed therapy. Patients requiring re-treatment were more successful with self-supervision than DOT.

Q16_Limt:
The sample size was smaller than expected so the authors were not able to draw separate conclusions on the relative effectiveness of supervision in the two sites.

Q17_Conc:
At high rates of treatment interruption, self supervision achieved equivalent outcomes to clinic DOT at lower cost. Self supervision achieved better outcomes for re-treatment patients. Supportive patient-provider relations, rather than the authoritarian surveillance implicit in DOT, may improve treatment outcomes and help control TB.

Q18_Recc:
The authors recommend reconsideration of DOT as the internationally recommended approach to treatment. They state that resources allocated to DOT could be diverted to improve the management and supervision of staff and clinics, and to writing and posting of reminders for patients who may have interrupted their TB treatment.


