# background

background:
The Tuberculosis Behavioral and Social Science (TB BSS) literature review project was funded by the Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination (DTBE). The literature review was conducted by a team of behavioral and social science researchers from Abt Associates, Inc., under the guidance of DTBE. The main goal of this project was the review and abstraction of materials on tuberculosis-related behavioral and social science research published between 1980 and 2004 identified by extensive literature searches.   

Systematic Literature Search 

A systematic database search of the BSS literature led to the identification of numerous TB BSS research and evaluation articles, as well as nonresearch documents (e.g., concept/position papers, book chapters, and conference proceedings.) In addition to identifying current TB BSS research, a goal of this literature review was the identification of research gaps and the establishment of priorities for future TB BSS research and practice.   
 
Database of Abstracted Materials Used in the Literature Review  

A systematic review of the TB BSS literature was completed and materials were summarized using an abstraction tool.  The data were entered into a Microsoft ACCESS database and used in data analysis and report writing. A total of 246 TB BSS materials identified through the literature review process were abstracted and included in the database. A summary of the proportion of research, evaluation, and nonresearch articles included in the database is provided below:

Type of Material                                Number         (%)

Research articles                               162            (65.8%)
Evaluation articles                               21             (8.5%)
Nonresearch documents                      63            (25.6%)

Total number of materials reviewed      246  

Qualifying Notes 

Much of the data abstracted from the literature were copied verbatim from the articles in order to collect data in an objective format across several literature reviewers.  As such, the original article should be referred to when citing information from this database to ensure copyright protections and to ensure accuracy.


# instructions

instructions:
I.  How to save database output:
- Go to the “File” menu and select “Export.”

- User will be prompted by a “Save” window to choose the directory where you wish to save the file. Choose a directory at this prompt.

- User will also be prompted to choose a file format for the document.  You must choose “Rich Text Format(.rtf)” in the “Save as type” box at the bottom of the window. 

II.  How to print documents:

- Go to the “File” menu and choose “Print.”  

- User may also use the keyboard shortcut of Ctrl + P.

- The document will be saved as a “Rich Text Format(.rtf)” file that can  be easily opened in Microsoft Word and converted into the “Microsoft Word(.doc)” format.


# Switchboard Items

ItemText:
TB Behavioral and Social Science Research Literature Review Database


ItemText:
Background: Information regarding development of the TB BSS Literature Review


ItemText:
Instructions for Use: Directions for printing and saving database files


ItemText:
Bibliography: View and print citations of all abstracted materials included in the database


ItemText:
Keyword Search:  Search all abstracted material included in the database using a single keyword or text string


ItemText:
Individual Article Reviews:  View the response for each question on the abstraction tool for an individual article (Note: User must have the 3-digit article ID to use this feature, see Bibliography for 3-digit article ID)


ItemText:
Article Reviews in Report Form:  View and print a 3-page summary of each abstracted material. (Note: User must have the 3-digit article ID to use this feature, see Bibliography for 3-digit article ID)


ItemText:
Complete Set of Article Reviews:  Comprehensive set of 3-page summaries for all 246 abstracted materials included in the database (Note: This feature produces a 738-page printed report)


ItemText:
Exit database:  User will exit the database (Note: Any unsaved data from searches will be lost)


# TBLit001

Q1_Title:
Local perceptions of tuberculosis in a rural district in Malawi

Q1_Author:
Banerjee, D., Harries, D., Nyirenda, T., & Salaniponi, F.

Q1_Journal:
International Journal of Tuberculosis and Lung Disease

Q2_Key:
TB, perceptions, traditional healers, Malawi, Sub-Saharan Africa

Q6_ReQue:
To determine 1) the number of patients treated by traditional healers, 2) the type of diseases managed by them, 3) the perceived causes of these diseases, and 4) how both patients and healers looked at TB.

Q8_SampCom:
276 healers; 4 focus groups with TB patients and families, number not specified

Q14_Desc:
During November and December 1997, in-depth interviews and structured questionnaires with traditional healers and focus group discussions with TB patients and their guardians were conducted.

Q15_Outc:
Traditional healers recognized four main causes of disease, related to why the patient is sick rather than what the patient is suffering from.  276 healers saw approximately 4600 patients a week, managing a variety of diseases, mainly of a chronic nature.  24% of patients seen by the traditional healer had a cough, including patients with TB.  Traditional healers believe they can cure TB, and have therefore been briefed on the infectious form of TB (smear-positive cases).  The possibility of including traditional healers in early diagnosis has been explored.

Q17_Conc:
There is a need to address local beliefs in health education and possibly find ways of involving healers in supervision of treatment.  Cooperation and mutual respect between traditional healers and western health workers should be encouraged.

Q18_Recc:
How to involve traditional healers in supervising treatment still needs to be explored.


Q1_Title:
A Social Science Approach to Strengthening India's National Tuberculosis Programme

Q4_TypeArt:
Non-research: Conference consensus paper (include conference proceedings)

Q14_Desc:
The article was a speech delivered at the TB Association of India conference. It contains an overview of TB health services using the perspective of the “New Public Health” in TB control. The author incorporates a social analysis approach in reviewing India’s National TB program.

Q15_Outc:
The major components of the speech include (1) Social Science Input in Health Programs; (2) Heritage of TB Work; (3) Formation of National TB Program – Planning and Programming; (4) Health Administration; (5) Target Oriented Programs; (6) Monitoring and Evaluation of NTP; and (5) International Efforts.

Q18_Recc:
Recommendations for improving India’s National TB Control program are given and examples include building critical mass of public health workers; restructuring to place public health specialists in key positions; considering the constraints on the general health services area; and involving other TB institutions.


Q1_Title:
In search of factors responsible for noncompliance among tuberculosis patients in Wardha District, India

Q2_Key:
compliance, TB, India, health beliefs, social support, doctor-patient interaction, health promotion

Q6_ReQue:
The study compares and contrasts health beliefs, demographic and socio-economic variables, causative beliefs, supports and barriers of compliant and noncompliant tuberculosis patients.

Q8_SampCom:
Total=102  (52 Compliant; 50 Non-Compliant TB Outpatients)

Q14_Desc:
The study assessed 52 compliant and 50 noncompliant tuberculosis outpatients who were prescribed antituberculosis drug regimens by means of a questionnaire with previously fixed response options in order to identify which factors were responsible for having complied or not.  The dependent variable of noncompliance was defined as the failure to take antituberculosis drugs for more than 15 days duration.  The independent variables consisted of sociodemographic variables (e.g., gender, marital status, age, type and size of family, and the relationship with the head of the family) and socio-economic indicators of social class.

Q15_Outc:
Differences were found between compliers and noncompliers, especially the health belief items of health motivation, the perceived severity of the disease, costs and benefits of the treatment regimen and self-efficacy.  Compliers reported more physical symptoms at the onset of the disease, whereas more noncompliers mentioned a deteriorated health condition at the time of interviewing.  Relationships existed between:  presence of social support and cooperation with the treatment procedure; compliance behavior and knowledge of specific aspects of TB, the origin of TB and features of the drug regimen; and satisfaction with the health care provider and continuation of drug intake.

Q16_Limt:
Non-compliant patients who dropped out of treatment given by the District TB Center were different from patients of the Indian Council of Medical Research project in the duration of the treatment.  This may lead to confounding findings since compliance decreased over time.  Another limitation was that the interviewer knew whether an interviewee had completed treatment or not.

Q17_Conc:
Non-compliant patients in Wardha District, India faced numerous obstacles in completing treatment.  Poor socioeconomic conditions, fostering of health-damaging beliefs, lack of sound health information, lack of social support from family or nonrelatives, and awkward relationships with health care providers, all contributed to poor health outcomes.

Q18_Recc:
Health promotive investments, such as social and economic aid, increased social support, training and supervision in TB patients, should increase patient adherence and treatment completion.


Q1_Title:
Neighborhood Poverty and the Resurgence of Tuberculosis in New York City, 1984-1992

Q1_Author:
Barr, R., Diez-Roux, A., Knirsch, C., & Pablos-Mendez, A.

Q6_ReQue:
The article assessed the relation between neighborhood poverty and TB at the height of the epidemic and longitudinally from 1984 through 1992 in New York City.

Q8_SampCom:
4,722 incident cases of TB [matched to neighborhood for analysis: 3343 (1992) and 1379 (1984)]

Q9_Other:
For each neighborhood, TB &  AIDS incidences were calculated in 1984 & 1992 with data from the NY Bureau of TB control and AIDS Surveillance;. Census data poverty rates;

Q10_AduUSBrn:
African American, Hispanic, White, Asian

Q13_Comm:
Several findings of statistical significance were discussed and 95%  CI were provided. Poisson Regression analysis.

Q14_Desc:
The authors investigated whether poverty remained a major risk factor for TB at the peak of the New York City TB epidemic using an ecological study design. Given the large and differential changes in poverty rates in neighborhoods in New York City in the 1980s, the study examined the longitudinal association of changes in poverty with changes in TB incidence.  We performed two analyses of NYC neighborhoods: (1) cross-sectional, at the peak of the epidemic in 1992, and (2) longitudinally, comparing the change on neighborhood poverty from 1980 to 1990 with the change in neighborhood TB incidence from 1984 to 1992.  For both analyses, neighborhoods were used as the unit of analysis and were defined by the census block group.

Q15_Outc:
For 1992, 3343 TB cases were mapped to 5482 neighborhoods, yielding a mean incidence of 46.5 per 100 000. Neighborhood poverty was associated with TB (relative risk = 1.33; 95% confidence interval = 1.30, 1.36 per 10% increase in poverty). This association persisted after adjustment for AIDS, proportion foreign-born, and race/ethnicity. Neighborhoods with declining income from 1980 to 1990 had larger increases in TB incidence than did neighborhoods with increasing income.

Q16_Limt:
Several limitations (and efforts to address them) were discussed:  The lack of individual-level socioeconomic information on cases and non-cases made it impossible to investigate individual-level associations.  Ecologic studies may be subject to confounding.  For reasons of confidentiality, measure of AIDS incidence was less precise than other measures.  Geographically proximal block groups may share traits relevant to TB more than distant block groups do.  Residual correlation between may violate assumption of independence and lead to incorrect standard errors.   The undercount of the population by 1990 Census may have led to an overestimation of TB incidence in poorer neighborhoods in this analysis.

Q17_Conc:
Leading up to and at the height of the TB epidemic in New York City, neighborhood poverty was strongly associated with TB incidence. Public health interventions should target impoverished areas. These findings suggest the importance of poverty in shaping the epidemic.

Q18_Recc:
Ultimately, as TB control programs become victims of their own success, priority should be given to impoverished neighborhoods.


Q1_Title:
Delay in the diagnosis, notification and initiation of treatment and compliance in children with tuberculosis

Q1_Author:
Beyers, N., Gie, R., Schaaf, H., van Zyl, S., Nel, E., Talent, J., & Donald, P.R.

Q2_Key:
South Africa, children, delay periods, compliance, urban, rural

Q6_ReQue:
Objective:  This study investigated the delay periods and the compliance with therapy in children with tuberculosis.

Q8_SampCom:
172 children  (49 with probable TB; 123 with confirmed TB)

Q13_Comm:
A P-value of less than 0.05 was regarded as significant.

Q14_Desc:
The purpose of this study was to investigate the delay between the onset of symptoms and diagnosis of tuberculosis, the delay between diagnosis and commencement of therapy, the success of the system of tuberculosis notification and compliance with therapy for children with tuberculosis.

During the study period there were 49 children with probable and 123 with confirmed pulmonary tuberculosis.  The children were divided according to their home address into urban and rural areas.  The urban areas were further divided into urban settled communities and urban squatter communities, which included squatters in informal settlements and in peri-urban farming communities.

The present study was conducted in Tygerberg Hospital in Cape Town, and in the local authority health clinics where patients with TB receive supervised daily therapy on weekdays.  The duration of symptoms was determined on the basis of the presenting complaint given by the child’s parent or caregiver.  Six months after the date of initial diagnosis, a request form was sent to the clinic closest to the child’s home requesting information concerning whether treatment was started, whether the child’s caretaker had complied with the treatment, and how many dosages of treatment the child had received.  The definition of compliance in the local clinics was taking more than 80% of prescribed dosages given five days a week for six months.

Q15_Outc:
The mean period from first symptoms until presentation was 4.3 weeks, from presentation until notification 5 weeks, and from notification until therapy 0.9 weeks.  Significantly fewer children in the urban squatter communities received therapy than in urban settled (P=0.02), rural agricultural (P=0.0001) and rural settled (P=0.09) communities.  12% of children did not complete their therapy.  The fact that children from rural farming communities experienced a greater delay in presentation may indicate less ready access to health care facilities for these communities.

16% of children who were notified as having tuberculosis never received therapy.  It is perhaps significant that the majority of these children were from the rapidly growing squatter areas which have a very high population mobility; health workers may have to use special strategies and close liaison with community organizations to trace patients from these communities.  By contrast, although presentation was delayed in the children from rural communities, once diagnosed the delay in the initiation of treatment was short and 98% of the children could be traced and treatment commenced and completed in all but 2 of the 43 children.

Q17_Conc:
The delay in presentation (“patient delay”) was shorter than the delay in diagnosis (“doctor delay”).  Failure to trace children and to complete therapy was particularly likely to occur in urban squatter communities.  Easier access to health care facilities may shorten the “patient delay” while greater awareness of tuberculosis and proper investigation of children may shorten the “doctor delay.”

Q18_Recc:
Education of parents as to the importance of TB symptoms would, together with easier access to health care facilities, aid the earlier presentation of a variety of respiratory conditions including TB.  Once within the influence of a health care facility, education of the parent or caretaker as to the nature of tuberculosis and the necessity for long-term treatment may play a critical role in ensuring attendance for treatment and completion of treatment.  Nonetheless, ease of access to a treatment center may be an equally important determinant.


Q1_Title:
Increasing the Efficacy of School-Based Directly Observed Therapy: From Needs Assessment to Program Implementation

Q6_ReQue:
This assessment addressed factors for adherence to TB treatment in the pediatric population in the Essex County, New Jersey, school districts with the school nurse as caregiver primary target population.

Q7_TheoBas:
Health belief model; DOT model for children

Q13_Comm:
p-value set at .05 to determine significance

Q14_Desc:
In Essex County, New Jersey, a needs assessment was given to school nurses who administered DOT to school children TB patients <18 years old.  In 1996, a brief cross-sectional questionnaire needs assessment emphasized nurse characteristics and DOT challenges.  This study later followed-up with interventions based on questionnaire results. Descriptive analyses were also conducted.

Q15_Outc:
The 1996 questionnaire identified categories of barriers leading to poor adherence such as patients not coming for treatment, low nurse-to-student ratio; routine tasks and care for other students diverting nurses’ attention from DOT administration and following up with nonadherent students.   In response to the assessment, several interventions were implemented, expanded, or enhanced in all schools in which DOT was being administered.  As a result of these interventions, the 1996 school-based DOT adherence rate increased to 91.1% and continued to be above 90% for 3 consecutive years.  School-based DOT adherence rates continued to increase through 1999.

Q16_Limt:
Small population size. The use of retrospective experiential data may have been tainted by recall bias.  The survey questions (especially closed-ended ones) could have been subject to the investigators’ biases.

Q17_Conc:
This assessment and the subsequent increase in adherence employed a combination of school nursing practice and academic research to increase adherence to TB treatment.  Given the collaboration between school nurse and local TB programs, cooperative programs for making care suitable to health care workers’ and patients’ lives is of value in increasing adherence.  Increasing pediatric TB drug adherence through caregivers such as school nurses not only increases individual health but also lowers societal exposure to TB.  The school-based DOT program was able to produce positive results when applied to another setting.


Q1_Title:
Treating Tuberculosis: The Essential Role of Social Work

Q2_Key:
TB, treatment compliance, adherence, ecological perspective, social work

Q3b_Both:
The focus of the article was on both influences on patient adherence and structural/organizational characteristics of incorporating social work and TB control.

Q6_ReQue:
To determine the effect and role of social work in the treatment of TB via its potential influence on patient adherence to treatment.

Q8_SampCom:
7 patients in a TB sanitorium, all English speaking

Q14_Desc:
Article describes results of seven qualitative interviews conducted with patients at the sole remaining TB sanatorium in the US.  English- speaking patients were approached and asked to participate in interviews to elicit their thoughts, feelings, and beliefs about TB treatment.

Q15_Outc:
Patients reported unrealistically high levels of medication compliance and no relationship between number of pills taken and compliance with the regimen (both of which are contradicted by other research findings).
Article highlights several major findings among patient experiences:
-Most experienced a delay in TB diagnosis
-Patients received little education about their medications prior to initiation of therapy.
-Patients experienced low levels of continuity among medical providers
-None of the patients had successful outpatient treatment
-Noncompliance typically happened when symptoms began to dissipate. 
-Patients understood the consequences of noncompliance
-Few patients had high levels of social support.
-Most identified the characteristics of lifestyle that increase risk of TB incidence
-None of the patients could identify a social worker in the sanatorium or describe the role of social work in their treatment.

Q16_Limt:
Generalizability is severely limited both due to the specific nature of the sanatorium patient population (repeat non-adherers court ordered to undergo care) and the lack of representativeness of the sample to members of the sanatorium population (all members were English speaking, which under represents Creole-speaking and Spanish-speaking members of the hospital pop, which make up a large percentage).

Also, it appears that there was a very strong self-report bias in measurement of treatment adherence.

Q17_Conc:
“Interventions which lack a holistic view of persons and their interactions with the environment will invariably fail” and thus social work has an essential role in treating TB.


Q1_Title:
Transmission of tuberculosis in San Francisco and its association with immigration and ethnicity

Q1_Author:
Borgdorff, M., Behr, M., Nagelkerke, N., Hopewell, P., & Small, P.

Q2_Key:
TB, transmission, molecular epidemiology, reproductive rate

Q6_ReQue:
The aim of this article was to determine TB transmission dynamics in San Francisco and its association with country of birth and ethnicity.

Q8_SampCom:
1855 reported cases in SF => 1574 confirmed culture positive => 944 used in analysis

Q14_Desc:
Restriction fragment length polymorphism (RFLP) typing was performed on M. Tuberculosis isolates from culture-positive pulmonary TB patients in San Francisco (1991 – 1995) using IS6110 as a probe.  Patients were assigned to clusters based on mycobacterial isolates with identical DNA fingerprints.  Clusters were assumed to have arisen from recent transmissions.  A transmission index was defined as the average number of culture-positive pulmonary TB cases generated by a single source case and calculated for subgroups.

Q15_Outc:
The transmission index was higher in the US-born (0.59) than in foreign-born groups (0.21), and was highest in blacks, in particular those aged under 35 years.  The increased transmission index among blacks was not explained by smear-positivity, HIV infection, or increased susceptibility to disease progression.

Q16_Limt:
One limitation of the study is that analysis was based on strains with five or more copies of IS6110.  Exclusion of low copy number isolates biases downwards the transmission index of those who are US-born, black HIV infected, and aged under 35.  As in the present analysis a high transmission index was found for US-born Blacks, the exclusion may have let to conservative estimates.

Q17_Conc:
US-born TB cases generated more secondary cases than immigrants.  Young blacks appear to be a high-risk group for TB transmission.  These results suggest the need to develop interventions targeted towards this risk group.


Q1_Title:
New Concepts in Nursing Management of the TB Patient: A Community Training Program

Q6_ReQue:
The objective of this study was to see if two interventions (a collaborative referral program, and a training program for community workers) could improve return rates for TB test reading, as well as referral follow up rates for Native Americans in the Chicago area.

Q14_Desc:
This article describes the need (and opportunity) for a nursing intervention in a part of Chicago that is home to a high percentage of Native Americans. The opportunity arose out of a TB case and a subsequent screening program at a community drop in center experienced low return rates (61%) and a referral completion rate of 67%. Both of these rates were cited as “below average” so two interventions were developed to see if they would improve these rates. Community outreach workers from several agencies serving high risk populations were trained to read TB test results. A linkage agreement was established between several agencies serving this community.

Q15_Outc:
During a four month period after the intervention (training of community workers to read test results) the return rates improved from 7% to 17%.

Q16_Limt:
The author states they were unable to document the fact that the follow up return rate was due to the community workers’ intervention.

Q17_Conc:
There is a great opportunity to expand the role of community health nurses which would include training community health workers to be part of an extended health care team.


Q1_Title:
Community-Based Strategies for Tuberculosis Control

Q1_Journal:
Tuberculosis: a sourcebook for nursing practice

Q1_Pages:
177-196. New York: Springer Publishing Company.

Q6_ReQue:
This chapter focuses on both the traditional and innovative TB control activities provided by public health departments.

Q14_Desc:
This chapter focuses on both the traditional and innovative TB control activities provided by public health departments.  Traditional activities include case finding, contact investigations, and nursing case management; innovative strategies and models of care include the use of incentives and enablers to promote adherence to therapy, public-private partnerships, and community based educational campaigns.

Q17_Conc:
Public health departments have a crucial role to play in TB control efforts.  They will continue to play such a role as community health care is strengthened, and their legal mandate to protect public health is continued.  Support of public health department TB control efforts, including necessary funding for nurses, services, and programs, are necessary to strengthen the successful effort to control TB in the United States.


Q1_Title:
Tuberculosis Prevention Practices and Perspectives of Physicians in DeKalb County, GA

Q2_Key:
Physicians, prevention, screening, isoniazid, attitudes

Q6_ReQue:
Objective:  To determine physicians’ attitudes and practices relative to screening for and preventing tuberculosis among outpatients.

Q8_SampCom:
793 physicians (1621 questionnaires mailed, 848 respondents; 793 completed); 62 physician telephone interviewees

Q13_Comm:
The statistical significance of differences in proportions was determined using the chi-square test, with P<0.05 considered significant.

Q14_Desc:
The authors of the study describe the attitudes and practices of physicians relative to tuberculosis prevention in DeKalb County, GA.  Physicians were surveyed because of their key role in tuberculosis prevention, especially in performing screening tests and in prescribing.  Physicians were asked about their recent experience with tuberculin skin testing; the indications that they used in ordering skin tests; the type of skin test they used; their experience with prescribing isoniazid preventive therapy; and, if they had not prescribed it in the previous year, their attitudes concerning isoniazid.

Q15_Outc:
Whereas 92% of primary  care physicians had ordered the test, the proportions for the other specialty groups were substantially lower.  The patter for baseline skin testing was different among primary care specialties.  The practice was quite common among pediatricians (83%), but less prevalent among family practitioners (63%), general practitioners (41%), and internists (39%, P<0.001).  Large differences were found among specialty groups in the proportions of physicians who, after the completion of their medical training, reported ever having started a patient on isoniazid preventive therapy.  The highest proportion was among primary care physicians (73%), and the lowest among specialists with limited or no ongoing direct physical care of patients (21%).  Although 54% of medical and pediatric specialists reported ever having started a patient on isoniazid, there were differences within the group according to specialty.  For example, that practice was especially common among pulmonologists (100%) and infectious disease specialists (100%).  

Physicians who had neither started nor renewed a prescription for isoniazid preventive therapy within the previous year were asked to respond to statements about the therapy.  Prescribing of isoniazid was not considered within the medical specialty of 78% of surgeons, 87% of physicians in specialties with limited or no ongoing direct physical care of patients, and 81% of obstetricians-gynecologists.  Among PCPs, in contrast with other specialty groups, only 11% indicated that prescribing isoniazid was not within their medical specialty.  Their most frequent responses were that many patients do not like taking isoniazid (18%), that managing the side effects of isoniazid would make the physicians uncomfortable (8%), and that managing isoniazid preventive therapy was not adequately reimbursed (9%).

To validate the results of the mail survey, the authors telephoned 62 physicians who were primary care physicians or medical or pediatric specialists.  Physicians were administered the same questionnaire that they had received in the mail.  The survey had about 70% power to determine whether, compared with mail survey responders, the mail survey non-responders were two-thirds as likely to report having ordered outpatient tuberculin skin tests in the previous year.  Although responders to the mail questionnaire reported somewhat more frequent ordering of the tuberculin skin test and isoniazid than non-responders, those differences were not statistically significant.

Q16_Limt:
First, in any survey using a questionnaire, the problem of non-response must be considered.  Given that our study was based on a single mailing to achieve physicians, who replied anonymously, we believe that the 53% response rate was good.  Although the telephone survey found that mail survey responders and non-responders differed somewhat, those differences were neither statistically significant nor substantial.  Second, to maximize the response rate, our questionnaire was brief.  Questions were qualitative rather than quantitative because our primary interest in this study was whether a physician practiced a prevention modality, rather than how often.  Third, the study was limited to one Georgia County, and confirmation of our findings in other geographic areas would strengthen the findings’ generalizability.  However we do not believe that our findings are unique to DeKalb County, Georgia.

Q17_Conc:
The authors found that primary care physicians were the physician group most commonly involved in tuberculosis prevention activities.  Medical and pediatric specialists were significantly less likely to be involved in those activities.  Our findings raise particular concern for tuberculosis prevention, given two current trends in the supply of primary care physicians.  First, declining proportions of medical school graduates are interested in and matching to primary care specialty residency training positions.  Second there is a continuing decrease in the proportion of physicians who practice primary care specialties.

Q18_Recc:
To enhance tuberculosis prevention, recommendations and incentives for adopting preventive practices need to be designed for the increasingly specialized medical practice environment.


Q1_Title:
Traditional healers and pulmonary tuberculosis in Malawi

Q1_Author:
Brouwer, J., Boeree, M., Kager, P., Varkevisser, C., & Harries, A.

Q6_ReQue:
To investigate the use that TB patients in Malawi make of traditional healers and traditional medicine.

Q8_SampCom:
89 TB positive patients; 7 traditional healers

Q12_Oth:
Traditional healers residences, living in Blantyre

Q14_Desc:
A questionnaire study was carried out on 89 smear-positive pulmonary TB patients admitted to QECH.  Seven traditional healers in Blantyre were also interviewed about their knowledge, attitudes, and practice of patients whom they considered to have TB

Q15_Outc:
Of the 89 patients, 33 (37%) visited a traditional healer before seeking regular medical care.  Patients spent a median length of 4 weeks with the traditional healer.  During this time, 24 patients did not improve or deteriorated while on traditional treatments.  No patient was referred to the medical service by the traditional healer.  All traditional healers claimed to know about TB.  4 said they would refer a patient to hospital if their treatment was not curative.  In 1995, six traditional healers claimed to have cured 116 patients with TB.

Q16_Limt:
A limitation of this study is that it only selected patients who did not get better with traditional treatment.  Those who were cured, if any, would not have been referred to a hospital or a health center.

Q17_Conc:
It is important to involve traditional healers in the educational activities of the National Tuberculosis Control Program.  These healers need to be taught to recognize and refer patients with TB, whom they should not treat, but at the same time be encouraged to administer safe treatments for conditions which are more amenable to their practice.


Q1_Journal:
The Journal of Law, Medicine, and Ethics

Q6_ReQue:
This study explores the relationship between homelessness and TB and the relationship between homelessness, TB and HIV using examples from New York City, Boston and San Francisco.

Q11_USA:
New York, Massachusetts & California:  New York City, NY; Boston, MA; San Francisco, CA

Q14_Desc:
Homelessness has existed in America since colonial times, and the attitudes, analyses, and solutions offered through the succeeding centuries have evolved far less radically then recent media attention might suggest.  Our society has had ambivalent feelings toward the poor and homeless.  The outbreak and progression of TB in such settings reflects both societies’ ambivalence towards this population, as well as a misguided belief that modern medicine can be viewed in the abstract as curative and divorced from the social context to which all disease is inextricably bound.  Unless and until these beliefs are addressed and altered, TB among the homeless will continue unabated.  This study explores this relationship by citing examples in New York City, Boston and San Francisco.

Q17_Conc:
I think we are back to “Pauperism is the consequence of willful error, of shameful indolence, of vicious habits.  It is a misery of human creation, the pernicious work of man, the lamentable consequences of bad principles and morals.”  Leaving aside the factual inaccuracy and ideological offensiveness of this attitude, so long as we so regard and treat the homeless with TB, we will never eliminate the disease.


Q1_Title:
Resurgent Tuberculosis in New York City.  Human Immunodeficiency Virus, Homelessness, and the Decline of Tuberculosis Control Programs.

Q6_ReQue:
The descriptive research was performed in an attempt to determine potential predictors of TB positivity and success of treatment.

Q8_SampCom:
224 TB inpatients admitted during first 9 months of 1988.  Of these, 79% were male, 53% reported a history of alcoholism, 45% reported they were homeless (with an additional 23% indicating they were “unstably housed”), and 40% were HIV+ or had AIDS.

Q14_Desc:
All inpatient TB patients admitted between January and September of 1988 were included in the study for prospective analysis.  Interviews were conducted with 193 (of 224 total), and chart abstractions were also used to gain information.  Follow-ups took place at 4-month intervals following discharge, and lists of those lost to follow-up was compared to the NYC computerized registry at 8 and 15 months.

A multivariate regression analysis was performed to determine factors significantly associated with non-compliance to TB treatment and follow-up.

Q15_Outc:
In addition to the characteristics of the sample provided above (item #8), 82% of participants were unemployed, and 26% had been previously treated for TB. 

Following discharge, the majority of patients were lost to follow-up, although 27% were readmitted with active TB within 12 months.  In terms of regression analysis, the authors state “noncompliance was significantly associated with homelessness, alcoholism, and the absence of AIDS or ARC [AIDS-related complex].”  Crack users were “totally noncompliant”.  Although female patients were less likely to complete treatment than males, gender was found to be only “borderline in significance” as a predictor of noncompliance.

In addition to the quantitative research results, the authors present a detailed historical perspective of the decline in public sector TB services between 1968 and 1988 and the subsequent increase in TB incidence in New York City.

Q17_Conc:
Non-compliance with TB treatment is a significant problem, which appears to be more pronounced among individuals with substance abuse and unstable housing (including the homeless).  Contrary to popular assumption, the authors suggest that the increase in TB rates in New York City are due to increasing primary TB infection as well as TB/HIV coinfection.

Q18_Recc:
The authors suggest that strategies such as “prolonged initial hospitalizations, residential TB treatment facilities, and aggressive community-based supervision” will need to be reinstituted to address the increasing rates of TB in New York.


Q1_Title:
Zip Code-Level Risk Factors for Tuberculosis: Neighborhood Environment and Residential Segregation in New Jersey, 1985-1992

Q2_Key:
TB, boolean method, segregation, racial disparities

Q6_ReQue:
What are the most common risk factors in each zip code with very high TB rates for various racial/ethnic groups?  What are the similarities and differences in risk factors among zip codes with very high TB rates across various racial/ethnic groups?  The study describes various configurations of risk factors found in actual zip codes characterized by very high TB incidence.

Q9_Other:
Census data; NJ public health department TB case data

Q10_AduUSBrn:
White, Hispanic, African American, Asian

Q10_ACIUSBrn:
White, Hispanic, African American, Asian

Q11_USA:
New Jersey:  Paterson, Jersey City, & Elizabeth

Q14_Desc:
This article examined zip code-level risk factors associated with very high TB rates among Whites, African American, Hispanics, and Asians in New Jersey from 1985 to 1992, a period of when TB was on the rise in the United States.

Q15_Outc:
For Whites and Asians, risk factors were rare in zip codes with very high TB rates.  In agreement with the distribution of TB cases by age and foreign born status, this suggests case among Whites may be caused by reactivation, whereas cases among Asians may be imported.  In contrast, Hispanics and African Americans were exposed to risk factors than may facilitate TB transmission.  Among Hispanics, high contact with immigrants was an important factor.  African Americans were the group most frequently exposed to multiple risk factors.

Q17_Conc:
For Hispanics and African Americans, zip code-level risk factors were associated with very high TB rates.

Q18_Recc:
Additional use of the role of context in the epidemiology of infectious diseases and to suggest that high risk also may be defined in ecologic terms.


Q1_Title:
Adherence to Tuberculosis Preventive Therapy among Latino Immigrants

Q2_Key:
Adherence, TB, Latino, LTBI, Preventive Therapy

Q3b_Both:
Internal influences were discussed such as factors associated with adherence to preventive therapy.  External influences were used in the discussion analysis of the study findings.

Q6_ReQue:
This study of Latino immigrants examined adherence to appointments and medication taking during the 6 months of preventive therapy for latent tuberculosis infection.

Q7_TheoBas:
Orem’s self-care deficit theory guided the development of this study.

Q10_AduFrBrn:
Latino immigrants (mostly Central American & mostly female)

Q13_Comm:
Statistical significance is discussed.   Findings with no statistical significance were of interest in this study.

Q14_Desc:
This study employed a descriptive survey using personal interviews and medical record reviews to study adherence and the relationships between variables and the differences between groups.  The study examined the influences of demographic factors, self-assessment of health, side effects, and support on adherence to appointment keeping and medication-taking among 65 Latino immigrants with latent tuberculosis infection from a clinic in the Washington DC area.

Q15_Outc:
This study indicated that 81% of respondents kept their initial clinic appointment while only 60% continued to keep clinic appointments at the end of six months.  For medication adherence, the rate dropped from 89% at one month to 65% at six months, which is less than the national average (69%).  None of the demographic factors accounted for adherence. No other variables such as side effects, perceived health status, or support, had any significant impact on adherence.

Q17_Conc:
Findings indicate that adherence to treatment is a problem of great magnitude among Latino immigrants.  Appointment keeping findings point out a gap in the client’s view of the seriousness of LTBI and/or in structural problems of accessing therapy.  These findings show the complexity of the issue and support Farmer’s 1997 views of the social forces, which influence non-adherence to TB therapy.  Orem’s conceptualization of client self-care served as a useful framework for the study.  The subject of adherence, particularly as influenced by client culture, remains a complex and intriguing problem for nurses.

Q18_Recc:
Community health nurses should assess: client knowledge and provide necessary information to enhance client’s self-care abilities; assess the potential risk of client non-adherence/intention to adhere.  Public health professionals need to augment their health teaching in a culturally sensitive way at their first contact with clients.  Emphasis needs to be placed on giving clients information about the treatment plan and the untoward effects of non-adherence.  Based on Latino immigrant values, suggestions included:  continuity of care by same public health nurse, direct face to face contact is more usual and acceptable than telephone or recorded messages, and teaching programs should include the family’s health.  For clients who lapse in treatment adherence, DOT twice a week may be a possible intervention.  Additional interventions may involve Latino community leadership who could urge the community to participate fully in treatment.


Q1_Title:
Latino Immigrants' Explanatory Models of Tuberculosis Infection

Q2_Key:
LTBI, Latinos, belief, preventive therapy

Q6_ReQue:
This study elicited Latino patients’ explanatory models of cause of TB infection using 3 questions:  What is the cause of your infection?  What do you fear most about your infection?  What results do you expect to receive from treatment?

Q7_TheoBas:
Kleinman’s framework for eliciting an explanatory model was used

Q8_SampCom:
65 Latino immigrants with LTBI receiving preventive therapy at a county health dept.

Q10_AduFrBrn:
Latino immigrants with LTBI & receiving preventive therapy at a county health department

Q13_Comm:
n/a (No information on statistical significance reported. Only descriptive statistics were provided.)

Q14_Desc:
The study examined the explanatory models related to TB infection in a convenience sample of Latino immigrants receiving preventive therapy.  65 clients were interviewed; most were female (80%) and Central American.  This report is part of a larger study of TB preventive therapy adherence among Latino immigrant clients of a large health department in a metropolitan area.

Q15_Outc:
Content analysis revealed several themes.  Although 50% of clients did not know the cause of their infection; most offered a biomedical explanation of TB infection with statements about contagion.  Others opined a popular notion that infection was due to conditions in their country of origin. In terms of fear, responses most often suggested a theme of worry about developing the disease (n=26).  Clients’ treatment expectations focused on stopping the disease and not being contagious (n=34); these are similar to the professional sector expectations.

Q16_Limt:
Research was conducted in a public health clinic, which may have influenced clients’ responses.  The study focused on TB infection (not TB disease), which presents a major difference to health care providers. However, participants may not differentiate between them.  Participants were interviewed at various points in their preventive therapy, which may pose a limitation.

Q17_Conc:
Findings suggest that preventive therapy clients explain their infection in terms of their life experience in their country of origin, common sense, and limited information available to them.  Client responses suggest the presence of popular and folk beliefs concerning their TB infection and emotional responses of anxiety and fear.

Q18_Recc:
In developing cultural competence, health care providers need to: 1) recognize the emotional response of Latino clients to their infection and use their understanding of the cultural context to offer support and encouragement.  2) Provide culturally and linguistically relevant pamphlets and videos for clients and their families.  3) Increase their awareness of cultural influences on clients’ understanding of their health situation. 4) Focus treatment plans and programs within a context that recognizes sociocultural experience from which clients’ views of illness emerge.


Q1_Title:
Americans' Knowledge and Perceived Risk of Tuberculosis

Q6_ReQue:
What is the knowledge and perceived risk of TB among the general population?

Q14_Desc:
The present study examined the knowledge and perceived risk of TB in 19,127 U.S. residents who responded to the 1994 National Health Interview Survey (NHIS).  The questionnaire contained 5 questions on TB knowledge and perceived risk.  The overall response rate for the TB questions was 77% (14,727).

Q15_Outc:
Some general knowledge of TB was found, as were several misconceptions. Perceived risk of contracting TB was low. Perceived knowledge was higher than actual knowledge. Gender, education, income, and ethnicity were associated with knowledge and perceived risk. Older people responded correctly to questions about TB knowledge more often than younger people.

Q16_Limt:
Limitations of the present study relate to the scope and nature of the available data from the NHIS.  Although additional measures of TB knowledge and perceived risk would have expanded the contribution of the study, the national survey provided only five questions on this topic.

Q17_Conc:
A widespread and major effort must be launched to acquaint the public with TB and its re-emergence as a threat in the 21st century.  New information and materials should be developed so that nurses (and others) can address the lack of knowledge regarding TB in the U.S. population.

Q18_Recc:
Must inform children and their families about the effect of TB and their need to be knowledgeable about it.  TB should be included as a topic in health curricula in U.S. schools.  Nursing schools also must address the subject of TB in depth by including modules addressing the screening and management of latent TB infection and active TB.


Q1_Title:
Tuberculosis and Social Stratification in South Africa

Q1_Journal:
International Journal of Health Services

Q6_ReQue:
This is a report on the current situation of TB and social stratification in South Africa.

Q14_Desc:
TB continues to be a barometer of poverty, determined by racial classification, in both town and countryside in the Republic of South Africa.  This report on the current situation is based mostly on official published data regarding the nature of the disease, presentation, diagnosis and registration.  All of these factors depend crucially on an individual’s racial classification and urban or rural residence.

Q15_Outc:
Despite the fact that whites with the disease stand a greater chance of being diagnosed than their black counterparts, because they have very much better access to health care, the risks of TB for people classified by the state as "black" and "colored" are 27 and 16 times, respectively, the risk for whites.  Black gold miners, the nutritional elite of the workforce, have also experienced an increase in TB rates.  TB accounts for 50% of all black compensation cases and some 2.5% of white cases.  The risks of TB have increased over recent years among "coloreds" and blacks.  Rates of TB meningitis have also increased over the past decade, and show the dramatically worse health care available to people classified as black and "colored."

Q17_Conc:
Although about 60,000 new TB cases are reported in the country each year, there have been cutbacks in the resources available for TB control and treatment.  Among people classified as black and "colored," it progress is insidious and relentless. In South Africa today the situation is far from being under control.  Over the past five to six years, there has been an increase in poverty-related diseases, such as TB, among the white population.  TB rates among whites have increased to their highest levels since the 1950s.  However, compared with the continuing increase in incidence of TB among blacks, the increase among whites is small; whatever has changed in South Africa, the burden of poverty is still being shouldered by blacks.


Q1_Title:
Three Models of Social Work Intervention with Tuberculosis Patients

Q2_Key:
social work, TB, socioeconomic factors, South Carolina, Blacks

Q3b_Both:
The social work models assess socioeconomic factors in the lives of tuberculosis patients

Q6_ReQue:
The study describes how the South Carolina public health agency has relied on social workers to expand the range of methods used in tuberculosis intervention, thereby improving the health status and the general quality of life for affected individuals and at-risk groups.

Q7_TheoBas:
Stated theoretical basis:  ecological perspective directed at environmental as well as individual change.

Q8_SampCom:
2,131 total:  183 non-adherence patients +1,900 screened individuals [model I]+ 36 TB cases [model II]  + 12 hospitalized patients [model III]

Q10_AduUSBrn:
Mostly Black males; Black females; few White & Hispanic individuals

Q10_ACIUSBrn:
Mostly Black males; Black females; few White & Hispanic individuals

Q12_Oth:
Counties in South Carolina with high TB rates were targeted for interventions; screenings conducted in churches, schools, shopping malls.

Q14_Desc:
Three models of social work intervention with a primarily Black, low-income, tuberculosis population in South Carolina are described. The models emphasize community organization (model I), case consultation (model II), and medical social work methods (model III). No study design was stated.

Q15_Outc:
The lasting results of this process (model I) are expanded social support for promoting individual help-seeking and compliance with the medical regimen as well as improved general health education for a highly vulnerable population.  An essential aspect of tuberculosis case consultation (model II) is that the case assessment and intervention focus on the total life needs of the individual rather than the individual as a tuberculosis patient.  This example illustrates the contribution social work can make to primary tuberculosis care.  All surviving hospitalized patients (model III) completed their medical regimen or were about to complete the treatment during the study period.  As a result of social work support, hospitalization was the first step toward greater life stability for many tuberculosis patients.

Q17_Conc:
In South Carolina, each of the 3 tuberculosis social work models involves multiple change targets.  In almost all cases the patients were treated effectively and they received assistance in solving their social and economic problems.  Eradication of tuberculosis will occur only by treating it in the broader context.  Social workers are essential to this comprehensive approach to tuberculosis intervention.

Q18_Recc:
As in the early days of tuberculosis intervention, interdisciplinary collaboration is essential.  Social workers and primary health care professionals must be able to communicate openly about medical, psychosocial, cultural, and economic factors related to health problems.


Q1_Title:
Studies on factors influencing patient's, doctor's, and total delay of tuberculosis case-detection in Japan

Q1_Journal:
Bulletin of the International Union Against TB

Q2_Key:
patient, doctor, delay, case finding, tuberculosis

Q6_ReQue:
To find out the present actual status of passive case-finding of TB patient, to know how to improve it, and to discover the factors influencing the patient’s delay, doctor’s delay and total delay.

Q7_TheoBas:
Model of the passive case-finding process

Q8_SampCom:
3,915  (1,248 in first survey; 2,667 in second survey)

Q14_Desc:
Two surveys were conducted in Japan with patients and doctors.  The first survey (n=1,248) was used to reveal the actual breakdown of every step of passive tuberculosis case finding.  The second survey (n=2,667) was carried out to confirm the results of the first survey, and to identify the factors influencing the patient’s delay, doctor’s delay and total delay (combined patient + doctor delay).

Q15_Outc:
The majority of patients were diagnosed as having TB soon after the onset of symptoms but some were diagnosed a very long time after onset (range: 7 to 480 days).  The distribution of patient’s delay was different from area to area, as were doctor’s delay.  But the most influential factor was whether or not X-ray examination was done at first medical institution visited.  Median was only 13 days among patients examined by X-ray, whereas that of patients not examined was as long as 50 days.  Among 442 cases whose total delay exceeded 2 months, 180 cases (41%) visited a medical institution within 2 months of symptom onset, but doctor’s delay exceeded 2 months; 158 cases (36%) visited a medical institution >2 months after onset of symptoms, whereas doctor’s delay was relatively shorter.

Q17_Conc:
Shortening the patient’s delay as well as doctor’s delay is very important in tuberculosis case finding.  There is a strong need to study appropriate counter-measures for patients whose delay exceeded 2 months, as well as the counter-measures for doctors whose delay exceeded 1 month or 2 months.


Q1_Title:
Does Fear of Immigration Authorities Deter Tuberculosis Patients From Seeking Care?

Q3b_Both:
This study addresses both domains, as the focus is on health seeking behaviors of persons (internal influences) which are impacted by fears related to immigration and other policy-related issues (external influences).

Q6_ReQue:
What is the relationship of symptoms, immigration related variables and the TB patients delay in seeking medical care.

Q10_AduFrBrn:
Study population included Latino, Asian, and others but countries of origins were not specified.

Q14_Desc:
The authors surveyed patients with active TB in Los Angeles, to asses the relationship of immigration related variables, symptoms and delay in seeking care.

Q15_Outc:
Most patients sought care for symptoms rather than as a result of the efforts of public health personnel to screen high risk groups or trace contacts of individuals with TB. Very few respondents felt that going in for care would lead to trouble with immigration authorities, but fear of immigration authorities was the cultural variable most closely associated with symptomatic patients delaying care.

Q16_Limt:
Study design makes it impossible to evaluate the barriers faced by those who never seek care. Possible inaccuracy of self-reported data. 
Response bias may be possible, related to overall response rate of 60%

Q17_Conc:
Any legislation that increases undocumented immigrants fear that health care professionals will report them to authorities may exacerbate the current TB epidemic.

Q18_Recc:
The authors recommended against the implementation of laws or policies that would further deter undocumented immigrants from seeking health care for TB and other illnesses.


Q1_Title:
Why Do Symptomatic Patients Delay Obtaining Care for Tuberculosis?

Q1_Author:
Asch, S., Leake, B., Anderson, R., & Gelberg, L.

Q1_Journal:
American Journal Respiratory Critical Care Medicine

Q3b_Both:
This research addresses both the perceived barriers (internal) to seeking care as well as the actual barriers (external).

Q6_ReQue:
1) What proportion of active TB patients were identified through contact-tracing efforts and what proportion sought care as a result of symptoms; 2) How much clinically significant delay occurs among symptomatic TB patients; 3) Which access barriers best explain delay? In particular, does less perceived need for care or less severe disease best explain delay, or are social factors like unemployment or lack of a regular source of care more important?

Q8_SampCom:
526 eligible cases identified from county TB registry;  some not found or refused to participate, leaving 313 patients in the study

Q14_Desc:
This study sought to answer the question: what are the perceived access barriers that keep symptomatic TB patients from obtaining care? Interviews were conducted with public health TB patients in LA County. Data from the county TB registry was also accessed to supplement the data collected through surveys/interviews.

Q15_Outc:
Most patients (71%) had sought care for symptoms. Far fewer (15%) were diagnosed with TB after seeking care for another medical condition. Only 1% were identified as contacts of a TB patient, while 10% had been identified through a TB screening program. Of 248 patients with symptoms, 20% of those met the authors definition of a medical care delay likely to result in infection of contacts.

Q16_Limt:
A cross-sectional study limits the ability to determine cause and effect relationships. The outcome measure of delay in seeking care was necessarily self-reported, therefore subject to recall bias or misclassification of non-TB symptoms as those of TB. Forty percent of the target population was unable to be contacted. The authors chose to analyze the outcome variables dichotomously, which had limitations on the kind of analyses that could be conducted.

Q17_Conc:
These results support policies that reduce co-payments, increase availability of medical care, and decrease in waiting time in the office and for an appointment.  Policies that increase fear of immigration authorities among patients seeking care for TB may increase delay in seeking care. Contact tracing and screening programs can only have a limited effect in identifying active TB patients, as most seek care because of symptoms.

Q18_Recc:
Policies to control the spread of TB should encourage increased access to care, because perceived barriers to access are also associated with delay in obtaining care. Public education efforts to encourage persons with TB are important given the lack of understanding of the gravity of the disease.


Q1_Title:
Health seeking and perceived causes of tuberculosis among patients in Manila, Philippines

Q1_Author:
Auer, C., Sarol, J., Tanner, M., & Weiss, M.

Q1_Journal:
Tropical Medicine and International Health

Q2_Key:
pulmonary TB, health seeking, health providers, perceived causes of TB, Philippines

Q6_ReQue:
Health-seeking behavior, health seeking delay, perceived causes, and perceived quality of care related to TB were studied in interviews with 319 sputum smear-positive TB patients in the Philippines.

Q8_SampCom:
319 sputum smear-positive TB patients; case studies of 2 patients

Q10_AduIntl:
people in the Philippines (no specific racial/ethnic group was stated)

Q11_Intl:
Philippines:  Malabon (a municipality in metro Manila)

Q12_Oth:
22 gov’t health centers (part of Health departments above)

Q14_Desc:
A survey was conducted with 319 TB patients of 22 public health centers in Malabon, a municipality of metro Manila, Philippines.  The study examined how factors such as the ways people experience their symptoms and illness, perceived causes and experiences with the health care system, and considered how they may contribute to multiple health seeking and delayed treatment. Two case studies illustrate how these factors operate.  (70% respondents were male, 80% were between ages 20-60 years, and 87% considered themselves to be poor.)

Q15_Outc:
Only 29% of the respondents had gone first to a health center after onset of TB-related symptoms, and more than half (53%) had initially consulted a private doctor. A chest X-ray was obtained for nearly everyone (97%). Two thirds of the patients (66%) had received a prescription for drugs, and 29% had purchased and taken anti-TB drugs for at least three weeks before they came to a governmental health center. Concerning community interactions, 36% said they knew at least one person who had been treated for TB without success. The health seeking delay after symptom onset was relatively short - 64% of the respondents said they went to a health facility within 1 month. Case studies illustrate the rationale for health seeking and explain delayed initiation of appropriate treatment for many patients.

Q17_Conc:
Findings underscore the need for and indicate approaches to health communication for improved control of TB. Findings from interview narratives also suggest that improved interpersonal skills of health center staff and co-ordination between the private doctors and the health centers may substantially improve services for TB patients.  This study found that the family plays an important role in health seeking.  This study did not show a relationship between any perceived causes of TB and delayed health seeking, and the role of several other anticipated predictors of delayed health seeking remained unsubstantiated.

Q18_Recc:
Health communication to promote health and prevent illness should be conveyed to more than one person in the family.  Encouraging the public to always be accompanied by a family member when seeking health care and enabling community health workers to adequately convey health communication messages to the families in their houses are two approaches to strengthen family-based health communication.  Efforts to promote DOTS strategy must account for the human aspect of clinical interactions.  The technical and organizational aspects of TB control should not detract from appreciation of the human aspects of treatment and control strategies.


Q1_Title:
Improving the Quality of Healthcare Delivery to Homeless Tuberculosis Patients: A New Approach

Q2_Key:
TB, treatment adherence, homelessness, board and care homes

Q6_ReQue:
Article briefly describes a novel approach to TB treatment support using state-contracted “board and care” homes to house homeless patients for the duration of treatment.

Q9_Other:
Doesn’t specify, although medical status of patients is presented…

Q13_Comm:
No statistical tests were performed.  Only simple counts and percentages are presented

Q14_Desc:
The article presents a very brief overview of an intervention to house and offer support services (job training, substance abuse counseling, etc.) to homeless TB patients through the duration of their treatment.

Patients who were homeless at diagnosis were contacted at the hospital during initial 2 week stay and enrolled in the program.  Upon release from hospital, they are housed at a licensed, state-contracted board and care home in the community for the duration of care.

Q15_Outc:
Of 17 patients initially placed in the program prior to the publication date, 3 are still in homes and on therapy, 3 transferred to another residence and are still on therapy, 1 was lost to follow-up, 5 were discharged, and 5 successfully completed their treatment regimen.  Overall, 11/17 (65%) either successfully completed therapy or are likely to do so.

Q17_Conc:
The program’s success seems to justify the additional costs associated with the novel intervention.  Therefore, placement of homeless patients in a home facility for the duration of therapy is “desirable.”

Q18_Recc:
Continue to support and research novel approaches that go beyond “doing things the same old way.”


Q1_Title:
Knowledge, attitude and behavior of TB patients

Q2_Key:
Tuberculosis, patient knowledge, attitudes, perceptions, patient behavior, United Kingdom

Q6_ReQue:
Objective:  To gain “base-line information about the knowledge, attitude, and behavior of TB patients”

Q8_SampCom:
224  (of 259 patients, for 86.5% response rate)

Q13_Comm:
Only counts, percentages, and CIs were presented

Q14_Desc:
TB patients in the four districts of Birmingham’s health authorities were contacted to participate in the interview process.  In-person interviews were completed with 224 patients using a structured questionnaire that measured demographic items, knowledge of TB, attitude toward TB and care-seeking behavior.

Q15_Outc:
-Most patients (94%) did not initially suspect TB when symptoms began
-Non-white patients had lower levels of knowledge of signs and symptoms than white respondents.
-79% of patients did not believe the disease was infectious to their friends and family.
-Patients indicated “reluctance to discuss (TB) with others”

Q17_Conc:
“The study points out…the need for patient education about TB among the non-white population.”

Q18_Recc:
TB prevention and control strategy should include “Education programmes in ethnic minority languages aimed at the community most at risk.”


Q1_Title:
Evaluation of a unified treatment regimen for all new cases of tuberculosis using guardian-based supervision.

Q1_Author:
Banerjee, A., Harries, A.D., Mphasa, N., Nyirenda, T.E., Veen, J., Ringdal, T., Van Gorkom, J., & Salaniponi, F.M.L.

Q6_ReQue:
To determine whether directly observed treatment (DOT) during the initial phase of treatment supervised either in hospital, at health centres or by guardians in the community, was associated with 1) satisfactory 2-month and 8-month treatment outcomes, and 2) with a reduction of in-patient hospital-bed days.

Q13_Comm:
Chi-square test and 2-tailed Fisher’s exact test, with difference at the 95% confidence level. Relative risks and P values also calculated.

Q14_Desc:
Prospective data collection of all tuberculosis (TB) patients registered between 1 April 1996 and 30 June 1997, with 2-month and 8-month treatment outcomes, sputum smear conversion in smear-positive pulmonary TB patients (PTB) and in-patient hospital-bed days.

Q15_Outc:
Among the 600 new patients, 302 had smear-positive PTB, 150 smear-negative PTB and 148 extrapulmonary TB (EPTB). Eight-month treatment completion was 65% for smear-positive PTB patients, which was significantly higher than in patients with smear-negative PTB (45%) and EPTB (54%), due mainly to high 8-month mortality rates. The site of the intensive phase was determined in 596 patients: 178 (30%) received DOT from guardians, 115 (19%) from a health centre and 303 (51%) in hospital. At 2 months, mortality rates were significantly higher in hospitalised patients. Two-month treatment outcomes (including sputum smear conversion rates in smear-positive PTB patients) were similar between patients receiving DOT at health centres or from guardians.

Q16_Limt:
Potential problems with interpreting drug adherence data – data for patients in hospitals and health care centers was determined by inspecting treatment cards, while data for patients receiving guardian-based DOT was determined by collecting and inspecting DOT monitoring forms. The latter were not always completed by guardians and in some cases forms were missing. These problems may explain observed inferior drug adherence rather than failure to take medications.

Q17_Conc:
Decentralised DOT resulted in a 25% reduction in hospital-bed days in patients alive at 2 months compared with that predicted using the old regimens. Decentralising DOT to health centres and to guardians during the intensive phase is associated with satisfactory treatment outcomes.


Q1_Title:
Compliance with Tuberculosis Drug Regimens:  Incentives and Enablers Offered by Public Health Departments

Q6_ReQue:
What incentives are offered by state or local health departments to encourage TB patients to comply with drug regimens.

Q8_SampCom:
51: all states and the District of Columbia

Q10_AduOth:
TB program staff, including administrative and non-clinical staff members

Q11_USA:
all 50 states plus District of Columbia were surveyed

Q12_Oth:
State health department TB control programs

Q14_Desc:
This article presents results from a survey of TB programs in all 50 state public health departments and the District of Columbia. The programs were surveyed by mail to assess what kind of incentives (if any) state and local health departments offer to TB patients in order to improve compliance with treatment.

Q15_Outc:
Only about five states reported not offering any incentives. The type of incentives offered included cash, as well as free meals, transportation, clothing, and day care.

Q17_Conc:
Public health departments in almost all states are implementing incentives as advocated by TB experts.

Q18_Recc:
Adequate funding for TB screening and treatment programs, as well as for incentives and enablers to comply with TB treatment, is essential to combat this constant public health threat.


Q1_Title:
A Clinic Model for a Better Tuberculosis Treatment Outcome and Factors Influencing Compliance

Q1_Author:
Buri, P., Vathesatogkit, P., Charoenpan, P., Kiatboonsri, S., & Buranaratchada, S.

Q1_Journal:
Journal of Medical Association of Thailand

Q2_Key:
Tuberculosis treatment, compliance, treatment adherence, Thailand

Q3b_Both:
The research examined a number of factors influencing treatment outcome.  These factors included several internal (patient adherence to recommendations, attendance at appointments, etc.) as well as external (such as economic support, ease of access to appointments, etc.) factors.

Q6_ReQue:
To test a model of “effective and efficient outpatient care” and understand “factors determining patient non-compliance.”

Q8_SampCom:
160 (116 initial treatment recipients, 44 re-treatment patients)

Q13_Comm:
Significant differences (measured via chi-square) were found between those completing and defaulting out of TB treatment on several variables (see next questions).

Q14_Desc:
Article reports on factors influencing completion of outpatient TB treatment among 175 (160 in final analysis) individuals diagnosed with TB in the Bangkok region for whom chemotherapy was indicated.  Clinical information (missed appointments, treatment completion, etc.) and socio-epidemiological data were collected and included in the analysis comparing those completing treatment with those who defaulted.

Q15_Outc:
Overall, 86.9% of patients successfully completed treatment.  Factors in which significant differences existed between those who completed treatment and those who defaulted were:  regular (vs. irregular) “drug compliance”, those with shorter traveling time to appointments, those without other illness, those without “possible barriers to compliance”, and those who consumed alcohol regularly.  Additionally, there were no significant differences in default rates  or regularity of clinic attendance between initial and re-treatment groups.

Q17_Conc:
“This prospective study of 160 patients showed a great improvement in the default rate and in the compliance problem of re-treatment cases.”

Q18_Recc:
“These simple measures and the awareness of the at-risk patients who require extra-supervision may make the impact of tuberculosis chemotherapy more rewarding.”


Q1_Title:
Short-term Incarceration for the Management of Noncompliance with Tuberculosis Treatment

Q1_Author:
Burman, W., Cohn, D., Rietmeijer, C., Judson, F., Sbarbaro, J., & Reves, R.

Q2_Key:
alcoholism, DOT, homelessness, incarceration, noncompliance, TB

Q3b_Both:
A record review of TB cases and considers how incarceration as an intervention improved treatment completion. Both internal influences (patient adherence) and external influences (laws allowing for incarceration of noncompliant patients) are relevant.

Q6_ReQue:
The objective of this study was to review the use of incarceration for noncompliance with TB drug treatment.

Q8_SampCom:
424 cases of TB identified between 1984 and 1994 from records of the Metro Denver TB

Q14_Desc:
The researchers review the legal basis and practical application of quarantine for active TB, including the use of incarceration for noncompliance. They conducted a retrospective review of all patients treated in a urban TB clinic between 1984 and 1994, to identify those who were incarcerated and to evaluate the effectiveness of this approach as an intervention.

Q15_Outc:
Most of those who were incarcerated were US-born males born with a history of alcoholism and/or homelessness. Overall, 90% of incarcerated patients were successfully treated for TB.

Q17_Conc:
Homelessness and alcoholism were closely associated with the use of incarceration. Short term incarceration followed by outpatient, DOT was relative successful in the management of this difficult patient population.

Q18_Recc:
While a variety of measures have been used to encourage TB patients to comply with treatment, for some patients, the traditional measures (inducements, reminders, DOT) do not work and TB control programs should not be reluctant to employ legal means to help protect the public and prevent further transmission of TB.


Q1_Title:
Adherence with self-administered treatment of latent tuberculosis infection in Auckland

Q1_Author:
Calder, L., Marment, S., Cheng, A., Gao, W., & Simmons, G.

Q2_Key:
LTBI, treatment adherence, New Zealand, Isoniazid

Q3b_Both:
Article discusses both patient knowledge and provider education as factors in adherence

Q6_ReQue:
What is the level of adherence to self-administered treatment of LTBI, client understanding of treatment, and knowledge of signs and symptoms of liver-related side effects?

Q8_SampCom:
76 (of 105 eligible, 72.4% response rate)

Q14_Desc:
Patients at health clinic on treatment for LTBI were contacted in final 3 months of treatment or shortly after completion for interviews to assess self-reported adherence, knowledge of treatment regimen (via items about daily dose, relation to food, purpose of treatment, symptoms of hepatotoxicity, etc.).  Adherence was also measured via several additional measures such as pill counts, syrup volume measures, lid monitors, etc.

Q15_Outc:
-Overall completion rates were around 80%.  Adherence ranged from 72% (composite measures) to 89.5 (via self report).  Low levels of knowledge of side effects was also seen among participants.
-Overall, ethnicity (especially being Maori or Pacific Islander) was the only significant risk factor for non-adherence.  No other measured factors were significantly associated.

Q16_Limt:
-Bias due to self-report must be considered as possible cause of overestimation of adherence
-Some individuals who dropped out of treatment were not included in the interviews, thus results may not be reflective of entire population.

Q17_Conc:
Most patients knew why they were on therapy, but some did not.  “Repeated education about the rationale for treatment and the side effects of hepatitis is needed”

Q18_Recc:
-Use multiple measures of adherence in future research
-Suggests a need for more attention to adherence among certain ethnic groups
- Authors call for additional education for providers to be knowledgeable about  isoniazid side effects and pass info on to patients.


Q1_Title:
Participation by Health Professional Students in Tuberculin Screening

Q3b_Both:
The article studied reasons students training in several professional fields do not participate in TB screening which is mandatory twice a year at their institution.

Q6_ReQue:
Why do students not participate in mandatory screenings, and what are some ways to increase screening rates.

Q8_SampCom:
1357 surveys distributed; 596 respondents (overall response rate 44%)

Q10_AduOth:
students in graduate programs in Medicine, Nursing, Social Work, and Dentistry

Q14_Desc:
The article sought to understand why students did or did not participate in the twice yearly mandatory TB screening required of health professional students (nursing, medicine, social work, and dentistry). An anonymous survey was distributed to student mailboxes, and included some open ended questions.

Q15_Outc:
Higher participation in the August screening was seen as compared to the January screening. Many students reported reading their own test results rather than returning to the student health service to have the result read. Major reasons for participation included the fact that the program is mandatory, and the idea of health promotion/disease prevention (for both the student professional and for their patients). Reasons for non-participation included scheduling conflicts, having been tested elsewhere, and a concern that the testing is done too often.

Q17_Conc:
Mandatory testing should continue and the education of health professional students should be continued and strengthened

Q18_Recc:
A person-to-person approach requires spending time education clients. Excerpts from current medical literature can be distributed to students and TB testing time, and better methods of communication can be established. Testing can be done once yearly with more flexibility in testing sites and times.


Q1_Title:
Acceptance of Isoniazid Preventive Therapy by Health Care Workers After Tuberculin Skin Test Conversion

Q1_Author:
Camins, B., Bock, N., Watkins, D., & Blumberg, H.

Q1_Journal:
Journal of the American Medical Association

Q2_Key:
Isoniazid, health care workers, preventative therapy

Q6_ReQue:
Objective:  To examine health care workers’ (HCWs’) acceptance of and adherence to isoniazid preventive therapy in the setting of a comprehensive tuberculin skin-testing program.

Q8_SampCom:
125 HCWs total (91 in employee group; 34 in physician group)

Q14_Desc:
The authors of the study set out to examine the acceptance of and adherence to preventive therapy by hospital care workers—hospital employees, house staff, and medical students—at Grady Memorial Hospital in Atlanta, Georgia, a university-affiliated, public, inner-city hospital with a mandatory, comprehensive tuberculin skin-testing program that included physician referrals for all those with a positive tuberculin skin test.  The authors divided their cohort of 125 HCWs into two groups—an employee group of 91, and a physician group of 34—with the hope of discerning whether there were substantial differences in rates of adherence to preventive therapy.  All 125 subjects had a positive tuberculin test between July 1992 and January 1994.

Q15_Outc:
All 125 HCWs with a recent positive tuberculin skin test had a chest radiograph performed, 123 (98.4%) saw a physician, and 10 (84%) initiated preventive therapy.  Sixty-nine (66%) of the 105 HCWs who initiated preventive therapy (55% of the total 125) completed at least 6 months of isoniazid therapy.  More of the physician group than of the employee group completed preventive therapy (25 of the 34 [74%], vs. 44 of the 91 [48%], respectively; P<0.01).  Of the 36 HCWs who started but did not complete preventive therapy, 12 discontinued therapy because of an adverse drug effect and 24 were nonadherent.

Q16_Limt:
Determining adherence to self-administered therapy can be problematic.  The authors did not obtain blood or urine specimens from HCWs for detection of isoniazid.  Rather, adherence to therapy was based on medical and pharmacy records (e.g., filling six monthly prescriptions for isoniazid).
 
A second limitation of our study was that completion of preventive therapy for five HCWs in the physician group was assessed by self-report because no medical records or pharmacy records were available for review.

A third potential limitation of our study was that the employee and physician HCW groups were seen by different physicians; employees were seen by Grady Occupational Health Services Clinic physicians, while house staff and medical students were referred to Emory faculty physicians.

Lastly, the authors observed that a number of house staff treated themselves after their initial visit to a faculty physician.  Self-treatment was not recommended or condoned.

Q17_Conc:
In summary, in the setting of a comprehensive, mandatory tuberculin skin-testing program with protocols for physician referral, there was a high acceptance rate by HCWs of isoniazid preventive therapy.  However, even in our setting, a sizable proportion of HCWs, especially nonphysician HCWs,  did not complete preventive therapy.  Adhering to the treatment regimen of daily doses of isoniazid for 6 months proved to be difficult for a number of HCWs.

Q18_Recc:
For some HCWs, adherence and compliance rates might be improved by providing a more convenient or simpler treatment regimen such as directly observed administration of isoniazid preventive therapy twice a week.  Other agents with fewer side effects than isoniazid or other preventive therapy regimens consisting of multiple drugs for much shorter periods of time (e.g., 2 months), which are currently under investigation, may lead to higher rates of therapy completion.


Q1_Title:
Tuberculosis and Race/Ethnicity in the United States: Impact of Socioeconomic Status

Q1_Author:
Cantwell, M., McKenna, M., McCray, E., & Onorato, I.

Q1_Journal:
American Journal of Respiratory and Critical Care Medicine

Q5_Other:
analysis of census data compared with TB cases reported to CDC

Q6_ReQue:
The study looked at the interaction between increased risk of TB and multiple factors, including SES, race/ethnicity, and birthplace. The research question was: is the increased risk in TB experienced by racial and ethnic minorities in the US attributable to SES?

Q8_SampCom:
data on almost 160,000 cases reported to CDC were matched with Census data.

Q9_Other:
review of TB cases reported to CDC; US Census data

Q11_USA:
US (states not specified):  nationwide data used

Q14_Desc:
This article describes an analysis designed to determine the proportion of the increased risk of TB experienced by US racial and ethnic minorities, that is attributable to SES.

Q15_Outc:
For all six SES indicators analyzed, the relative risk of TB increased with lower SES. Adjusting for SES accounted for about half of the increased risk of TB associated with race/ethnicity among US born Blacks, Hispanics and Native Americans.

Q16_Limt:
Since this (like other studies) is an ecological analysis, it may erroneously assign group-based measures of disease-exposure association to individuals within the group and/or tend to overestimate the strength of the exposure-disease association. Also, there is potential for error introduced by assigning SES values to persons with TB based on median values for their demographic counterparts within a given geographic area such as zip code.

Q17_Conc:
SES impacts TB incidence via both a strong direct effect of crowding, manifested predominantly in overcrowded settings, and a TB-SES health gradient, manifested at all SES levels. SES accounts for much of the increased risk of TB previously associated with race/ethnicity.


Q1_Title:
Tuberculosis beliefs among recent Vietnamese refugees in New York State

Q1_Author:
Carey, J., Oxtoby, M., Nguyen, L., Huynh, V., Morgan, M., & Jeffery, M.

Q6_ReQue:
The purpose of this research was to identify the beliefs about TB among recent Vietnamese refugees in NY State.

Q14_Desc:
Researchers interviewed 51 newly arrived Vietnamese refugees about the symptoms and causes of TB, susceptibility to the disease, prognosis, skin testing procedures, prevention, treatment, and the disease’s impact on work and social relationships.

Q15_Outc:
Respondents correctly viewed TB as an infectious lung disease with symptoms such as cough, weakness, and weight loss. Hard manual labor, smoking, alcohol consumption and poor nutrition were believed to be risk factors. Many respondents incorrectly believe that asymptomatic latent infection is not possible and that infection always leads to disease. Nearly all respondents felt that having TB would adversely impact their work, family and community activities and relationships.

Q16_Limt:
It is unclear if the findings are generalizable to Vietnamese adults outside the two counties where the research was conducted.  The researchers were unable to control for the extent of a respondents exposure to TB education prior to immigration.

Q17_Conc:
Targeted patient education is needed to address misconceptions about TB among Vietnamese refugees and to help ensure adherence to prescribed treatment regimens.

Q18_Recc:
TB services, especially those given outside the clinic, should be delivered in a way that maximizes protection of patient confidentiality. Providers should allow sufficient time to learn each patients’ level of preexisting knowledge, beliefs, misconceptions, and concerns about the disease and it’s treatment. Community education may be useful in lowering the adverse social consequences of having the infection or clinical disease.


Q1_Title:
Legal Challenges of Tuberculosis in the Workplace

Q1_Journal:
American Association for Occupational Health Nurses Journal

Q2_Key:
TB, legal challenges, American with Disabilities Act, Rehabilitation Act

Q6_ReQue:
The aim of this paper is to describe legal precedents and challenges of TB in the workplace.  Discussing the rights and responsibilities of all parties involved and provide recommendations for the workplace.

Q14_Desc:
The increased transmission of TB and the potential for liability create a dilemma for employers.  Balancing the rights of the employee, employer, and the state as they relate to infectious diseases is difficult.  This paper cites a landmark case of School Board of Nassau County v. Arline (1987) as an example of legal precedent in order to provide recommendation for the occupational setting.

Q17_Conc:
The Arline (1987) case ruling illustrates that a person who is otherwise qualified for a position that contracts TB will be protected by the Rehabilitation Act, the Americans for Disabilities Act, and by the courts.  In legal reality, decisions related to the continued employment of infected individuals must be substantiated by an individual based on the best available evidence.  Therefore, ADA legislation allows an employer to require, as a qualification standard, that a person not pose a “direct threat” to the health and safety of themselves or others.  The guidelines are clear, the threat must pose a substantial risk and potential harm must be imminent.  In conjunction, the ADA does empower the medical and occupational health community to assess the risk based on “reasonable medical judgment” and “current medical knowledge” (ADA, 1990). Thus, today with the increased incidence of TB, employers must create an awareness of occupational exposure and provide protection for employees.

Q18_Recc:
Recommendations: Obtain a detailed health history and physical, including immunization records and evidence of TB testing on all employees.  Determine the risks of TB in the workplace and recommend screening if justified.  Report all positive screenings to the health department, and follow up and document treatment.  Document all test results, treatment, and follow up to insure that infected individuals are compliant with treatment protocols and to ensure that the timing of their return to work is appropriate.  Inform employees of benefits and rights.


Q1_Title:
Effects of an Incentive and Education Program on Return Rates for PPD Test Reading in Patients with HIV infection

Q1_Author:
Chaisson, R., Keruly, J., McAvinue, S., Gallant, J., & Moore, R.

Q1_Journal:
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology

Q2_Key:
HIV, TB, PPD, adherence, education, incentives

Q6_ReQue:
The purpose of this study was to evaluate the effectiveness of several strategies (e.g., food voucher incentive and patient education program) to enhance patient adherence with PPD skin testing.

Q8_SampCom:
659 total: 272 controls; 229 patients offered a food voucher only; 158 offered a food voucher plus education

Q9_Other:
PPD Logbook;  John Hopkins HIV Clinic Database

Q14_Desc:
This research focused on determining the impact of a food voucher incentive and patient education program on compliance with tuberculin skin test (PPD) performance in HIV-infected adults.  The setting was an urban HIV clinic.  The groups consisted of a control group and two intervention groups (one group received a food voucher incentive and the second group received a food voucher incentive and patient education).

Q15_Outc:
group were:
Control group – 35%
Food voucher only – 48%
Food voucher and patient education – 61%

Patients who returned for PPD reading were significantly older and more likely to be African American, male, injection drug users, and city residents than were patients who did not return for skin test reading.

Q17_Conc:
The study found that two interventions (food voucher and food voucher plus patient education) were associated with significantly increased return visit rates for tuberculin skin test reading in an urban HIV clinic.  The use of incentives or enablers is an important tool in enhancing compliance with medical regimens.

Q18_Recc:
Additional research is needed to determine the explanation of why less women versus men returned to have their PPD read.  In addition to this research, more studies of interventions to improve TB screening adherence in patients with HIV infection are required.


Q1_Title:
Transmission of Mycobacterium Tuberculosis Associated with Failed Completion of Treatment for Latent Tuberculosis Infection--Chickasaw County, Mississippi, June 1999-March 2002

Q1_Author:
Chamblee, T., Hartley, D., Holcombe, M., Parham, K., Upchurch, P., Webb, R., Robillard, A., Diem, L., Metchock, B., DeLuca, N., McElroy, P., Navit, T., Walton, W., & Dewan, P.

Q2_Key:
adherence, TB, LTBI, treatment completion, DOT

Q6_ReQue:
This article summarizes the results of an epidemiologic investigation of 16 TB patients and their contacts in Chickasaw County, Mississippi.

Q8_SampCom:
16 TB patients  (their 253 contacts were also discussed)

Q14_Desc:
This article described the outcome of an epidemiologic contact investigation of 16 TB+ patients in Chickasaw County, Mississippi and their contacts.  To identify barriers to LTBI treatment completion, MSDH in partnership with CDC, conducted three focus groups with TB-control staff, adherent and non-adherent LTBI patients.

Q15_Outc:
The 16 TB+ patients were:  US-born and HIV- (100%), Black 94%, male (63%) median age 31.  5 had been previously diagnosed with LTBI as a result of TB contact investigation but past attempts to treat them were unsuccessful due to refusal or stopped treatment.  They progressed to active TB and became sources of infection for 10 TB patients, including 5 patients <16 years old. All 16 patients completed a CDC-recommended course of treatment.  The 16 TB patients identified 364 contacts (253 persons).  LTBI was detected in 67 persons (26%). Patients with untreated LTBI in Chickasaw County were again offered treatment and MSDH hired outreach workers and expanded DOT for LTBI.

Q17_Conc:
To address patient concerns and misconceptions, MSDH initiated ongoing individual counseling during treatment for LTBI.  MSDH has engaged community leaders, churches, and civic organizations to disseminate TB-related educational messages.  The findings in this investigation underscore the need to ensure completion of treatment for LTBI by infected contacts of TB patients.

Q18_Recc:
Additional evaluation is needed to determine if patients outside high-risk groups (i.e., IDU, released jail inmates, and homeless persons) might benefit from incentives and DOT.  Qualitative evaluation of patient, staff, and system barriers might identify community-specific barriers to treatment initiation and completion.  Focus groups findings suggested that ongoing individual counseling for patients with LTBI and efforts to reduce stigma through community engagement might promote completion of treatment for LTBI.  A follow-up evaluation might help determine the effectiveness of these interventions.


Q1_Title:
Medical Anthropology: An important adjunct to international TB control

Q1_Author:
Chemtob, D., Weiser, S., Yitzhak, I., & Weiler-Ravell, D.

Q1_Journal:
Tuberculosis: A Comprehensive International Approach

Q3b_Both:
Looks at both management and socio-cultural aspects of TB control.

Q6_ReQue:
The chapter concentrates on the dynamic interaction between the socio-cultural circumstances of patient populations and management of TB.

Q14_Desc:
This chapter is written for medical practitioners and public health policy makers. It aims to educate the reader by raising awareness the importance of the socio-cultural aspects of TB patients. The discussion concentrates on the dynamic interaction of socio-cultural circumstances of patient populations and the management of TB. The data used to illustrate many examples relate to a migrant population but are pertinent to hard-to-reach populations. The chapter describes an anthropological study of TB among Ethiopian Immigrants in Israel.

Q15_Outc:
The relevance of social science to public health is discussed as it can help to delineate socio-cultural elements; identify barriers; analyze pitfalls of current interventions; and suggest solutions to overcoming difficulties. 
Basic concepts of social science in the context of public health, and key perspectives on TB literature are reviewed. In particular, the “knowledge, attitudes, beliefs, and behaviors” model for TB control is argued as only part of the overall picture and that significant social and economic inequalities should be considered in TB treatments.

Q17_Conc:
Barriers to TB treatment included cultural, social, political, and economic factors, all of which impeded successful treatment. The new National Program for Elimination of TB in Israel implemented some social science elements based on the experience of the study.

Q18_Recc:
Practical recommendations for health-care workers:
(1) Provision of comprehensive health education that is both culturally appropriate and empowering to patients.
(2) Assess and address social and economic barriers to treatment.
(3) Enlist support of respected community members.
(4) Encourage a TB control system of courtesy, tact, respect, and politeness.
(5) Treat all patients with dignity
(6) Maintain confidentiality of patients
(7) Use social science along with epidemiology to evaluate the qualitative and quantitative outcomes of the program


Q1_Title:
Tuberculosis Testing: Physician Attitudes and Practice

Q1_Author:
Cheng, T., Miller, E., Ottolini, M., Brasseux, C., & Rosenquist, G.

Q1_Journal:
Archives of Pediatric and Adolescent Medicine

Q6_ReQue:
To assess physician agreement with and adoption of American Academy of Pediatrics’ (AAP) recommendations on tuberculosis screening in children

Q8_SampCom:
762 (79% pediatricians; 21% family physicians)

Q11_USA:
Delaware, Maryland, Virginia, West Virginia, and the District of Columbia

Q13_Comm:
Univariate analysis was performed on all survey items; Chi square analysis was used to determine if any differences existed by physician type

Q14_Desc:
The purpose of this study was: 1) to determine TB screening practices and attitudes of community-based pediatricians and family physicians, 2) to determine if physicians were aware of the AAP 1994 recommendations, and 3) to assess the proportion of physicians who plan to change their TB screening practices in light of current recommendations.

Q15_Outc:
-762 surveys (79% pediatricians; 21% family physicians) were returned.
-The response rate was 66%.
-75% of the respondents were aware of the 1994 AAP screening recommendations.
-64% test children at low risk periodically; 81% test children at high risk annually.
-87% used multiple-puncture tests in 1993; 55% used MPTs in 1994.
-22% of the respondents adhere to the 1994 AAP recommendations regarding frequency, testing method, and reading the test reaction.
-Family physicians had lower adherence to the recommendations.

Q16_Limt:
The researchers did not include academic medical centers because it would include a large number of physicians, including sub specialists, who may perform little work in the field of primary care.  The exclusion of this group may have affected the survey results.  Also, some physicians may have falsely reported awareness of and compliance with the recommendations (social desirability bias) because they may not have wanted to appear that they were unaware of changes in policy.

Q17_Conc:
Physician practice of TB testing varies widely; most do not adhere to the 1994 AAP recommendations.  Most physicians vary the frequency and testing method based on a patient’s risk status.  The use of multiple-puncture tests has declined, although they are still widely used.  Accurate reading of screening tests remains a major concern.

Q18_Recc:
Greater efforts may be needed to communicate with practicing physicians if guidelines and recommendations are to be implemented.  Education and consensus building may be needed between practicing physicians and policy makers.

Further study is needed to explore potential barriers to adherence and to determine the effectiveness of different testing strategies in different populations.


Q1_Title:
Crowding and alcohol abuse as risk factors for tuberculosis in the Mamre population

Q2_Key:
tuberculosis, crowding, alcohol abuse, South Africa

Q3b_Both:
The study examined the influence of both crowding (external) and alcohol abuse (internal) as risk factors for TB in a particular population.

Q6_ReQue:
Are crowding and alcohol problems in a household risk factors for TB in a defined community (the Mamre population)?

Q8_SampCom:
40 cases and 84 controls, matched for age and gender

Q9_Other:
Measurements of the dimensions of all sleeping rooms in the subjects’ dwelling

Q11_Intl:
Republic of South Africa, community of Mamre

Q14_Desc:
Population based case control study to determine whether crowding and alcohol are risk factors for TB in Mamre, South Africa.  Authors identified 40 notified cases of TB and compared them with 84 randomly selected controls, matched on age and gender.

Q15_Outc:
There was no association between crowding and TB, but cases lived in houses that were significantly older than those of controls. There was an association between alcohol problems in the household and TB.

Q16_Limt:
No distinction was made between infection and disease in distinguishing cases and controls; the sample size of the community was limited to 5000; the study lacked temporality; and TB notifications were not validated against clinic or hospital records.

Q17_Conc:
Increasing house age and alcohol problems in a household are risk factors for TB in Mamre. Crowding is a problem, but not a strong risk factor for TB disease.

Q18_Recc:
Further studies using refined methods are needed to further evaluate the role of crowding in TB. The need for alcohol intervention campaigns in conjunction with TB control programs directed at high risk groups should be considered.


Q1_Title:
HIV and TB Among People Who Are Homeless and Mentally Ill

Q3b_Both:
Article discusses the need for interventions to address attitudes related to TB treatment and associated issues with homeless mentally ill populations.

Q6_ReQue:
Article highlights the rationale for focusing specific interventions to treat LTBI among homeless mentally ill individuals and provides an example of one such program.

Q11_USA:
New York:  New York City (examples provided from NYC)

Q14_Desc:
Article describes the rationale (based on CDC recommendations, relevant epidemiology, etc.) for advocating drug prophylaxis among homeless mentally ill individuals at risk for developing TB.  Furthermore, it highlights the characteristics and accomplishments of the Critical Time Intervention (CTI) in NYC.

Q15_Outc:
CTI is a program that provides case management and support for homeless mentally ill individuals making the transition from shelters to the community.  CTI model has recently been modified to include support for TB services within the case management framework.  This modification includes the use of a “community surrogate” to assist the patient in adherence with the medication regimen while in the community.  

Additionally, the article reports on educational interventions performed in the shelter prior to transition to teach the importance of TB medication adherence, side effects and interactions with psychotropic drugs, and overcoming barriers to treatment success such as lack of social support and access to providers.

Q17_Conc:
There is a need for programs to support TB drug therapy among homeless mentally ill people.  These programs can be integrated with existing homelessness support services to address barriers to treatment completion by homeless mentally ill.


Q1_Title:
Factors determining compliance with tuberculosis treatment in an urban environment, Tamatave, Madagascar

Q1_Author:
Comolet, T.M., Rakotomalala. R, & Rajaonarioa, H.

Q2_Key:
defaulter; tuberculosis; treatment; developing country; Madagascar

Q6_ReQue:
1) To identify the risk factors associated with default inherent in the health system, in order to propose suitable, effective operational changes within that system; and 2) to identify predictive factors associated with patient default (i.e., personal risk factors for defaulting from treatment detectable in the patients themselves), in order to be able to devote particular attention to those subjects at risk and thus reduce the number of patients who interrupt their treatment in an untimely fashion.

Q13_Comm:
Use of Epi Info 5; correlations were analyzed using the uncorrected Chi test and Fisher’s exact test.

Q14_Desc:
The article aims to study the characteristics of patients in an urban environment who defaulted from TB treatment in Tamatave or Ambatondrazaka, provinces of Madagascar, and to compare them with those patients who completed a full course of the same treatment.  The study allows suggestions to be formulated concerning the management of TB patients and early detection of risk of default.

Q15_Outc:
The case-control study was based retrospectively on 38 smear positive cases who had defaulted from treatment and 111 smear positive patients who had completed their treatment, during the same period and in the same location.  Default from treatment was significantly more frequent in male patients: 75% of defaulters were men, as opposed to 56% of controls.  Traveling time was also one of the determining factors associated with default.  Poor communication between patients and health workers were also significantly associated with default in the study.  False addresses given by patients are both a methodological bias and a risk factor for future default.

Q16_Limt:
60% of patients could not be traced because of false or incomplete address or change of address.  This can be seen as a methodological bias in the study.  The question that led to the finding that the patients were more likely to consider TB as a shameful disease may have been biased because they could also have been ashamed of their early interruption of treatment.

Q17_Conc:
Improved communication skills and attention from the medical staff could encourage more patients to complete their treatment.  Also, the elements of physical feeling of cure, fear of being rebuked by the doctor, financial difficulties, and one case where the patients felt sexually harassed by the doctor, can be considered as warning signs that are precursors or facilitators for the decision to default from treatment.

Q18_Recc:
It is necessary to refine the psychological evaluation of patients, using more subtle standardized tests or scales, in order to resolve the ongoing debate among health professionals, for whom the principal causes of default are to be found in the patients, and the public health authorities, who are more likely to incriminate weaknesses among health workers, in terms of communication and motivation.  The health team also needs to focus their efforts on the fact that there was a significant lack of information about the disease and its treatment found among defaulters versus controls.


Q3b_Both:
This is not a study but a concept/policy paper that touches on both internal and external influences on TB in women.

Q14_Desc:
This article presents a discussion of the impact that TB has on women. The paper describes: the epidemiology of TB in women; social and economic consequences of TB in women, issues related to TB control in women, and the challenge of TB combined with HIV/AIDS for women. The paper ends with some suggestions for addressing the concerns specific to women, in TB control strategies.

Q15_Outc:
The greatest obstacle to reducing the burden of TB in women is the lack of political will and inadequate financial resources for TB control.

Q18_Recc:
DOTS programs need to be gender sensitive when implemented, in order to ensure women have access to treatment. Women also need to be made more aware of the  risk of TB, therefore health education materials for women (as might be delivered at MCH clinics or through AIDS service organizations) should include info on TB. Health policy makers, donor countries, and NGOs need to be more aware of the impact of TB on women.


Q1_Title:
Defaulting From Tuberculosis Treatment At The Addis Abeba Tuberculosis Centre and Factors Associated With It

Q6_ReQue:
The aim of this study is to determine the default rate in TB treatment at the Addis Abeba TBC, to identify factors associated with defaulting, and based upon the results, to offer recommendation for the reduction of defaulting during TB treatment.

Q8_SampDes:
both probability & non-probability sample

Q8_SampCom:
1206 new TB cases; 200 defaulters (cases); 223 non-defaulters (control)

Q13_Comm:
Odds ratios, confidence intervals, statistical tests of significance, logistic regression model.

Q14_Desc:
The medical records of 1206 new TB patients registered over a 12 month period were reviewed for defaulting (missing TB treatment). A sample of the defaulters (cases) and the non-defaulters (controls) were then traced and interviewed. The two groups were compared by social, demographic and health variables.

Q15_Outc:
A high rate of defaulting was found – 82% of new TB patients defaulted in treatment over a 12 month period. The rates of defaulting were higher in males, in the older age groups, and in those living near to the TB center. Most of the defaulting occurred in the third and fourth months of treatment. Social problems and feeling of improvement were the top two reasons for patients to default. Inadequate knowledge, low educational level, nearer distance and negative attitude toward the TB center were found to be statistically significant predictors for defaulting (p < 0.0001, p < 0.001, p < 0.001, and p < 0.05 respectively).

Q16_Limt:
Differences in the set up, treatment schedule, follow-up and the type of patients using the TB center, as opposed to other health institutions, may limit generalizability.

Q17_Conc:
High rates of defaulting suggest important program inadequacies and an urgent need for change.

Q18_Recc:
The introduction of an alternative national TB control program with new strategies is recommended. 
New strategies should be explored such as: decentralization, follow-up of missed appointments, eliciting social support, behavioral modification by verbal encouragement, incentive and awards, patient reminder, health education, and free distribution of drugs at all levels.


Q1_Title:
Shared vision-a health education project designed to enhance adherence to anti-tuberculosis treatment

Q1_Journal:
The International Journal of Tuberculosis and Lung Disease

Q2_Key:
TB; adherence; health education; South Africa; treatment compliance; tuberculosis treatment

Q6_ReQue:
Is adherence to TB treatment increased by combining a patient centered interview with issuing of a patient education booklet?

Q7_TheoBas:
The article talks in general terms about health education theory, and the intervention was developed based on principles of social learning theory.

Q14_Desc:
The setting was two adjacent townships in Cape Town, South Africa.  The study was implemented using a cohort of the first 60 consecutive patients notified with pulmonary TB at both Clinic A and B.  Patients in the control group received standard clinic treatment, including an initial interview by a clinic nurse.  Patients in the intervention group received the “control group” treatment in addition to health education counseling.  This counseling included an initial patient interview conducted by a clinic nurse trained in interviewing techniques, and also receipt of a photonovella designed to reinforce the technical information give to the patient and to provide motivational support.  Full description of the intervention is included on page 182-183.

Q15_Outc:
The risk of non-adherence to treatment was significantly reduced among patients at the intervention clinic. The intervention affected both amount of meds taken and regularity with which they were taken.  Mean adherence rates were 95% and 83% for Clinic A (intervention) and Clinic B (control), respectively.

Q16_Limt:
Because the intervention was “packaged,” the authors state they cannot define which part of the intervention – or the combination – was responsible for the improved compliance.  Also, a possible confounding factor (increased motivation of clinic staff) was not measured.

Q17_Conc:
The relationship between the health care worker and the patient is very important in enhancing adherence to treatment.

Q18_Recc:
The positive results obtained from this health education demonstration project in Cape Town indicate that a wider and more rigorous evaluation of this approach is called for.


Q1_Title:
Tuberculosis in the community: 1. Evaluation of a volunteer health worker programme to enhance adherence to anti-tuberculosis treatment

Q1_Author:
Dick, J., Schoeman, J., Mohammed, A., & Lombard, C.

Q2_Key:
provider, treatment, health worker, adherence

Q6_ReQue:
To evaluate the effectiveness of this group of volunteer health workers in enhancing adherence of notified TB patients to TB treatment in South Africa.

Q8_SampCom:
351 TB patients (203 children + 148 adults)

Q10_AduIntl:
148 adults in the Elsies River Region of South Africa.

Q10_ACIIntl:
203 children in the Elsies River Region of South Africa.

Q13_Comm:
Several findings with statistical significance were reported.

Q14_Desc:
The purpose of this article is to describe a pilot project of community volunteer health workers, Operation Elsies River, which was implemented in a high TB prevalence area of Cape Town, South Africa.  The effectiveness of this group of volunteers in encouraging TB patients to complete their course of medication was compared to the other supervision options available in the same community.  A cohort study was conducted by monitoring all ambulatory primary and pulmonary TB patients notified in the Elsies River region over 6 months.

Q15_Outc:
Overall, 68% of notified TB patients in this group took 75% or more of their prescribed medication during the 6-month period.  The child group had a higher mean adherent rate (73%) to TB treatment than the adult group (62%).  The supervision option with staff dedicated to the treatment of TB, such as the clinic and the SANTA crèche, achieved better adherence results for pre-school children.  The supervision modalities for adults did not differ in their adherence performance even after adjustment for confounders.

Q16_Limt:
As the patients were responsible for selecting their own mode of supervision, the analysis of the association between supervision and adherence had to take possible confounders into account, (i.e., age, gender, and clinic for all subjects; plus marital status for the adult group). Supervision options for children and adults varied thus the 2 groups were analyzed separately.

Q17_Conc:
The supervision option provided by the volunteers did not significantly improve the adherence of adult patients to antituberculosis treatment.  Results suggest that pre-school children with TB should receive their treatment either at a crèche or via a volunteer from the community.

Q18_Recc:
Further research into the dynamics of the various clinics may lead to a better understanding of these results.  The complexities of treatment behavior and the vital role of the relationship between the health provider and the TB patient need further exploration.


Q1_Title:
Development of a health education booklet to enhance adherence to tuberculosis treatment

Q1_Author:
Dick, J., van der Walt, H., Hoogendoorn, L., & Tobias, B.

Q2_Key:
patient adherence; S. Africa, health education

Q6_ReQue:
The aim of this project was to involve clinic nurses in the process of exploring how TB patients experience their disease.  It was hoped that this investigation would dispel pre-existing assumptions and make the nurses more insightful into patient treatment behavior.

Q7_TheoBas:
Participatory research methods were utilized; Thorensen’s 5 sequential steps essential for facilitating patient adherence were used to develop the photo-novel.

Q8_SampCom:
56  (approx 7 nurses facilitated focus groups for  8 patients each

Q10_AduIntl:
patients with TB in the community of color in Cape Town – race/ethnicity not specified

Q14_Desc:
This paper describes a project in the Western Cape region of S. Africa designed to involve clinic nurses in the process of exploring how TB patients experience their disease. Information obtained from the qualitative research process was used to develop a photonovel which can be used to supplement the education given to newly diagnosed TB patients.  The project comprised 3 stages: 1) a descriptive phase,  2) phase to develop the health education tool , 3) pretesting of the health educational product.

Q15_Outc:
Much discussion focused on patients’ feelings about being diagnosed with TB (e.g., shock, disbelief, denial); TB is a stigmatized disease; 6 months of continuous daily attendance at a site of drug administration supervision was considered unreasonably long.  Participants identified the need for emotional support. Phase 2 results: Based on the semi-literate and low socio-economic status of target populations, the photonovel medium was chosen for health education material.  Focus groups of the photo-novel showed that respondents identified with the narrative depicted in the booklet.

Q17_Conc:
Focus group participants, who were all in treatment, were concerned with the psycho-social aspects of the disease but appeared unconcerned with the physical aspects of treatment.  The affective changes precipitated by the disease process, the stigmatization experienced and the length of treatment, were areas which affected their attitude to TB, and subsequently led to the decisions they made regarding adherence to treatment.  The nurses perceived that they had gained greater insight into the patients’ disease experiences as the focus groups gave the patients more opportunity to be expressive.  The value of  educational tools are limited if they are not developed around authentic experiences and based upon problems perceived by the target group.

Q18_Recc:
Treatment behavior is embedded in an intricate web of both social and psychological factors.  These factors may need to be addressed in patients requiring long-term treatment.


Q1_Title:
Fighting Tuberculosis in the 1990s: How Effective is Planning in Policy Making?

Q6_ReQue:
This paper argues that planning processes often fail in public health because they do not acknowledge and address the dynamic, political, and bureaucratic nature of the policy process.

Q11_USA:
Washington D.C. & New York:  New York City, NY

Q14_Desc:
Planning is a common tool for addressing important health issues, especially urgent ones, and has been reintroduced recently in several federal, state, and local public health programs.  This article presents a case study of planning and policy making concerning the reemergence of TB in urban areas, using Washington, D.C. and New York City as examples.

Q15_Outc:
Since the time of the study, TB cases have continued a steady decline in NYC (to 2053 cases in 1996).  In the District, reported cases of TB declined to 121 in 1994 and 102 in 1995, but then rose again in 1996 to 139.  Planning was unsuccessful in D.C. because it failed to acknowledge the important political and bureaucratic aspects of policy making.  In NYC, on the other hand, planning played a central role in policy-making efforts, and the health department took a leadership role in building consensus on the problem, formulating strategies, and overcoming implementation obstacles.

Q17_Conc:
The contrasting experiences with planning in these two cases provide several suggestions for ways that planning might be made more effective.  As an initial step, it is important to be able to identify and agree on scope, magnitude and to elucidate the dimensions of the problem.  Adequate data collection and improved communication processes are essential.  Second, planning processes need to address the inevitable politics of strategy formulation.  Third, developing strategies specifically designed to overcome implementation obstacles is key.  Resulting plans should be very specific, with activities, responsibilities, and time schedules for implementation outlined.  Finally, with a problem such as TB, when government plays a critical role in prevention, treatment, and providing resources, it is important for government to take a strong lead in formulating and implementing plans as part of their “policy development” function.  The government must recognize that groups outside the government play an important role in defining the problem, formulating solutions, and ultimately making sure that strategies are implemented.


Q1_Title:
Implications of social class and race for urban public health policy making: a case study of HIV/AIDS and TB policy in Washington, DC

Q2_Key:
TB, social class, HIV/AIDS, urban health, health policy, Washington DC

Q6_ReQue:
This paper explores how social class and race affect the public health policy-making process in an urban area.

Q14_Desc:
Ethnographic methods were used to collect and analyze information about HIV/AIDS and TB policy making by the Washington, DC Commission on Public Health.  Kingdon’s conceptual model of policy making was used to analyze and understand the process.

Q15_Outc:
The problems of HIV/AIDS and TB in DC have important social class dimensions that were not always made explicit, but were instead defined in terms of ‘race’ and ‘place’.  Social class considerations and racial politics shaped what policies were developed or not developed and implemented successfully or failed.

Q17_Conc:
This study, which has national and international implications, concludes that there is a need to improve our understanding of the complex social dimensions of public health problems; there needs to be more consideration of the politics of strategy formulation and how issues of social class and race affect this process; and public health needs to strengthen its constituency in order to build support for the successful development and implementation of policy.


Q1_Title:
Tuberculosis chemoprophylaxis: measuring adherence to the regimen

Q6_ReQue:
The purpose of this study was to develop and evaluate a setting-specific multiple measure of patient adherence to the regimen for preventative treatment of TB infection

Q8_SampCom:
Sample size (N) = 524 (175 English-speaking, Philippines-born; 194 English-speaking, US-born; 76 Tagalog-speaking, Philippines-born; 79 Korean-born; Korean-speaking

Q9_Other:
Urine testing; self reported pill taking; appointment keeping; interview with staff

Q14_Desc:
The Adherence Index is an additive measure of pill count plus self report, appointment-keeping, and urine test for metabolites of Isoniazid weighted for months in treatment.  The psychometric adequacy was evaluated for a sample of four language/cultural groups, including recent immigrants to the USA from Korea and the Philippines.  The purpose of this study was to develop and evaluate a setting-specific multiple measure of patient adherence to the regimen for preventative treatment of TB infection.

Q15_Outc:
The summary statistics indicated consistent means and standard deviations across language/cultural groups for the Adherence Index and its components.  One exception was found, in the significantly lower mean for urine test among Koreans when compared to English/Philippine patients (Tukey HSD post hoc comparison, p < 0.05).  This finding may have clinical significance, although the overall analysis was not significant, F(3,520) = 2.48, p = 0.06.  The lower mean may be due to the apparent rapid metabolism of INH noted among some Asian groups, resulting in negative tests for INH metabolites a few hours after taking the medication.

Q16_Limt:
Limitation in the study included the imprecise knowledge of INH metabolism across cultural groups and the need for a clearer understanding of the relations among acculturation factors and adherence patterns.

Q17_Conc:
The accurate measurement of adherence is basic to practice and research in TB care.  Our goal to encourage patients toward treatment completion requires further research in measurement, prediction, and intervention design for self-monitored preventative treatment.  The Adherence Index may be helpful in these activities.  The psychometric adequacy was supported in our clinical settings across four language/cultural groups.

Q18_Recc:
Further study of the anecdotally reported individual differences in INH metabolism by cultural group is needed to avoid confounding bioavailability and adherence.  The relation between a model of adherence behaviour and the Adherence Index will be the focus of a future study, including behaviours drawn from clinical experience, the literature on compliance, and interviews with patients, staff, and cross-cultural experts.  Future research including culture- and stage-specific adherence interventions combined with directly observed therapy for patients at high risk for dropout might yield improved adherence rates for patients in preventive treatment.  We suggest further evaluation across additional ethnic groups and in larger samples of our groups in other settings.  An accurate predictive model could help identify noncompliers early in treatment and facilitate intervention design through better understanding of patient beliefs and behaviour.  Rapid detection could lead to immediate, culturally-appropriate intervention and a possible decrease in nonadherence rates.  We recommend these areas of development and application for future research with the Adherence Index.


Q1_Title:
Tuberculosis: An Overview of Ethical and Legal Issues

Q1_Pages:
253-259.  New York: Springer Publishing Company

Q6_ReQue:
The purpose of this article was to discuss the ethical and legal challenges of TB and to document the recommendations made by members at a meeting conducted in April 1992 under the auspices of the United Hospital Fund.

Q14_Desc:
The article discusses the ethical and legal challenges of TB and documents the recommendations for future directions in the containment of TB and HIV made by scholars, clinicians, administrators, and policymakers of a 1992 United Hospital Fund meeting.

Q18_Recc:
Nurses need to develop an awareness of the historical and social significance of TB to provide more sensitive care to patients.  Nurses need to have a better understanding of the legal and ethical implications of TB-related policies and practices affecting patients and health care providers.  Many state laws that pertain to TB need revision to assure a balance between the individual and public good.

Recommendations of the working group on TB and HIV were made based on discussion of the following questions: (Refer to Table 14.1 on page 255 for specific recommendations)
1) Will effective TB control programs necessitate HIV screening?
2) Will efforts to protect those with HIV infection from TB require the adoption of restrictive employment practices?
3) What public health policies will be required by the challenge of TB to assure that individuals with the disease are identified and provided with treatment until cured?

The author states that although the recommendations mentioned in the table address issues in New York City, they can be extrapolated to the rest of the nation.  The author also urges readers with a special interest in legal and ethical issues related to TB to read the report on the working group in its entirety.


Q1_Title:
Compliance with Tuberculosis Treatment in Methadone-Maintained Patients:  Behavioral Interventions

Q1_Author:
Elk, R., Grabowski, J., Rhoades, H., Spiga, R., Schmitz, J., & Jennings, W.

Q2_Key:
behavior intervention, TB, compliance, treatment, substance abuse, methadone-maintenance

Q3b_Both:
Substance abuse, TB positive patients and methadone-maintenance treatment

Q6_ReQue:
The purpose of this investigation was to increase compliance with a prophylactic tubercular treatment regimen and simultaneously decrease drug use in a group of TB positive IV drug users applying for treatment for substance abuse. Several approaches were examined and the goal was to identify behavioral intervention elements that would enhance compliance.

Q13_Comm:
Group and within-subject comparisons using the z-test, t-test. Two tailed p values are reported.

Q14_Desc:
The purpose of this investigation was to achieve compliance with prophylactic TB treatment and simultaneously decrease drug use in a high-risk group of intravenous drug users. Two studies were conducted.

Q15_Outc:
Study 1: Subjects were 9 chronic opiate users who tested positive for tuberculosis and were placed on isoniazid (INH) and methadone. Methadone was dispensed contingent upon INH ingestion throughout. A within-subject, A-B design with contingency management interventions on drug use was implemented. Compliance with INH was 100% in 8 patients. Cocaine use remained high.

Study 2: Two patients, meeting same criteria as Study 1, participated in a within-subject A-B multiple baseline design. Methadone was dispensed contingent upon INH ingestion throughout. Successive decreases in cocaine use were reinforced in the contingent phase. Results: Compliance with INH was high. During contingency, both patients had over 40% cocaine-free urine samples compared with 0% at baseline.

Q17_Conc:
This investigation serves as a model for achieving compliance with TB treatment in opiate users.
It is crucial to establish compliance with the TB medication regimen, and this must be done with every effort to minimize the considerable risks of hepatotoxicity in patients who may be compromised.


Q1_Title:
Pregnant Women and Tuberculosis-Exposed Drug Abusers: Reducing Drug Use and Increasing Treatment Compliance

Q1_Journal:
Motivating behavior change among illicit drug abusers : research on contingency management interventions

Q2_Key:
drug abuse, pregnancy, TB, treatment compliance

Q6_ReQue:
This chapter focuses on the need for behavioral interventions to increase treatment compliance among two sub-populations of substance abusers: pregnant women and individuals exposed to TB.

Q7_TheoBas:
The author reviews six studies that utilized a combined approach of cognitive-behavioral counseling, and contingency management.

Q14_Desc:
This chapter focuses on the need for behavioral interventions to increase treatment compliance among two special sub-populations of substance abusers: pregnant women and individuals exposed to TB. The author reviews six studies that utilized a combined approach of cognitive-behavioral counseling, and contingency management (three with pregnant women who are cocaine abusers, three with cocaine abusers exposed to TB).

Q15_Outc:
Data from the studies described indicate that adjunctive contingency management intervention is effective in simultaneously decreasing drug use an increasing compliance with a medical regimen in a drug dependent population. These findings are said to have implications for cost effective treatment of substance abuse.

Q18_Recc:
When designing contingency management interventions, factors to be considered include targeting interventions directly at the behaviors requiring adjustment. This might mean targeting multiple problem behaviors, which is a different approach than is usually taken with other populations.


Q1_Title:
Knowledge and practices regarding tuberculosis:  a survey of final-year medical students from Canada, India and Uganda

Q1_Author:
Emili, J., Norman, G.R., Upshur, R.E., Scott, F., John, K.R., & Schmuck, M.L.

Q2_Key:
tuberculosis, clinical competence, medical education

Q3a_Other:
Provider knowledge and practice, for final year medical students

Q3b_Both:
Both domains are selected as the medical students were surveyed on both knowledge as well as the number of hours their curriculum dealt with TB and the hours of exposure they had to TB patients while in training.

Q6_ReQue:
Objective of the study was to compare the knowledge and practices regarding TB in final year medical students at three medical schools, from endemic and non-endemic areas. The hypothesis was that the three schools would differ significantly in the number of hours of curriculum devoted to TB, and the number of patients with TB seen by these students.

Q10_AduOth:
Final year medical students at three institutions

Q11_Intl:
Canada: McMaster University; India, Christian Medical College; Uganda: Makerere University

Q14_Desc:
The authors conducted a study with final year medical students at institutions in three countries (Canada, India, Uganda) to see if there were differences in the knowledge about TB and TB patient practices between students from endemic and those from non-endemic areas.

Q15_Outc:
Students from Uganda had higher knowledge scores but the differences were non-significant after adjustment for patient exposure and curriculum time. However, differences in practice scores were significant after these adjustments were made. Knowledge score, patient exposure, and curriculum time and patient exposure were statistically significant positive predictors of the total practice score. Overall the findings suggested that graduates possess an adequate knowledge base concerning TB.

Q16_Limt:
In order to maximize the response rate, the questionnaire was brief. The response rate varied by sites, probably related to the fact that the administration of the survey was different in one site (India). Because the survey was anonymous, there is no information on non-respondents to see if they differed from respondents.

Q17_Conc:
Significant differences were seen in the undergraduate exposure to TB, total knowledge, and practice competency at the three medical schools. The difference between the countries was most evident in the practice scores (students in Uganda performed batter than those in India and Canada).

Q18_Recc:
The authors make two major recommendations: a definition needs to be determined, for “core knowledge” that students and physicians require in order to be able to manage TB patients appropriately; and decisions need to be made on the best method to deliver the information to maximize it’s effect on provider practice


Q1_Title:
Attitudes Toward Tuberculosis of Final Year Medical Students From Canada, India, and Uganda

Q1_Author:
Emili, J., Scott, F., Upshur, R., Schmuck, M., & John, K.

Q2_Key:
TB, medical students, knowledge, providers

Q6_ReQue:
The authors hypothesized that students from endemic areas would have higher levels of awareness and therefore would be more receptive to issues pertaining to tuberculosis then their peers from nonendemic areas.

Q10_AduIntl:
final year medical students in Canada, India, & Uganda

Q14_Desc:
The authors surveyed final year medical students at 3 medical schools from endemic and nondemic areas (i.e., Canada, India, Uganda) regarding students’ knowledge, practices, and attitudes toward tuberculosis.  This article reported on students’ attitudes regarding TB epidemiology, rights of individual vs. society, treatment failure, and perceived risk and professional obligation.  Study design was not reported.

Q15_Outc:
160 surveys were returned with 155 completed attitude responses.  Analyses showed that 6 of 8 attitude items were slightly statistically different among the schools with minimal effect of curriculum time and patient exposure.    Attitudinal outcomes were reported:  Students generally agreed that TB is not a problem limited to developing countries.  They supported public health notification but were less likely to agree with stronger measures of isolation and enforcement of medical compliance. Respondents were more comfortable evoking stronger measures for patients with MDRTB.  Most students agreed that patient noncompliance is the biggest factor contributing to treatment failure.  After acknowledging the risk in treating patients with TB, they did not support a student’s right to refuse to care for TB patients  (Pearson r=.0893).

Q16_Limt:
The response rate ranged from 39.7% - 78.3% for the 3 medical schools.  Because no measure of social desirability was used, we can’t be sure the results represent the true attitudes of students surveyed.  Students may have answered in ways that made them seem more aware of tuberculosis or more receptive to dealing with patients with the disease.  Students who had more negative views may have chosen not to answer the questions.  Only 5 surveys contained incomplete data.

Q17_Conc:
Despite quite varied exposure to tuberculosis, students from endemic and nonendemic areas responded similarly on statements addressing attitudes toward tuberculosis.  The results indicate that students in 3 countries support public health and professional conduct in the management of the current tuberculosis epidemic.  Fostering such positive attitudes is a lifelong process that can be enhanced by encouraging individuals to consider their own attitudes in their continuing education.

Q18_Recc:
To effectively combat tuberculosis, physicians must be knowledgeable about the disease, competent in the fundamental principles of its management, and receptive to caring for patients with tuberculosis.  An integral part of any successful educational program is promotion of compassionate and comprehensive care.


Q1_Title:
Treating Hard-to-Treat Tuberculosis Patients in Massachusetts

Q1_Author:
Etkind, S., Boutotte, J., Ford, J., Singleton, L., & Nardell, E.

Q2_Key:
tuberculosis, treatment, “hard to treat” populations, homeless, substance abusers, Massachusetts

Q6_ReQue:
Questions addressed include: is long term hospitalization an effective TB control intervention among the homeless; is drug resistant TB among the homeless a threat to the general population.

Q14_Desc:
This article presents a review of TB in the state of Massachusetts, and the resources available in the state, for treatment and control activities. There is discussion of the “hard to treat” patients, and what makes them hard to treat (particularly homeless persons and substance abusers). The discussion also addresses minorities and the foreign born, and the need for culturally appropriate resources including bilingual outreach workers. Drug resistance is considered, as well as new models for long term hospitalization for these special populations.

Q15_Outc:
The authors state that in MA, hard to treat patients are increasingly being committed to involuntary, long-term inpatient therapy. While this treatment is expensive, it is also likely to be effective in breaking the chain of transmission. The authors describe  a new model of lower cost inpatient care that incorporates psychosocial rehabilitation techniques to modify the behavior of the hardest to treat patients.

Q18_Recc:
The authors suggest adoption of a new model of lower cost inpatient care that incorporates psychosocial rehabilitation techniques to modify the behavior of the hardest to treat patients. They conclude by stating that the upsurge of hard to treat TB in MA and elsewhere does not only depend on in patient care, but also on substantial changes in the socioeconomic order that perpetuates homelessness, substance abuse, crime and the transmission of both TB and HIV infection.


Q1_Title:
The Role of the Public Health Department in Tuberculosis

Q2_Key:
Health departments, surveillance, containment, outpatient care, case management approach, nursing case management, directly observed therapy, outreach workers, incentives, field investigation, inpatient care, restrictive measures, laboratory services

Q4_TypeArt:
Non-research: Other (Specify In Next Box)

Q4_Other:
illustrative/informative article on the various roles of health departments in addressing tuberculosis

Q6_ReQue:
Objective:  This article illustrates both the traditional public health methods of surveillance, containment, and prevention, and some of the newer strategies being employed to address TB control in today’s multifaceted environment.

Q11_USA:
Massachusetts:  Boston; New York:  New York City

Q13_Comm:
No research with statistically significant findings was provided to support the author’s claims.

Q14_Desc:
This article was an illustrative piece that focused on the legal foundations of TB public health prevention efforts; the traditional public health TB control strategies of surveillance, containment, prevention, education, and consultation; the relation between health care facilities and public health; newer strategies that focus on the linkages and partnerships needed within the community to accomplish the task; and the factors that affect the health department’s ability to achieve the goal of TB control and, ultimately, TB elimination.

* SEE ADDITIONAL COMMENTS FOR DETAILS ON TB CONTROL AND TRADITIONAL PUBLIC HEALTH STRATEGIES

Q15_Outc:
This article was a description of resources available to public health departments.  No key findings were revealed, although the author did make particular points.  She emphasized the importance of Directly Observed Therapy, outreach workers, social services, and contact investigations to health departments—each of these components allow health departments to extend themselves into communities and populations that might be more susceptible to TB because of economic plight and access to health care.

Q17_Conc:
This article shows that controlling TB will require an intensification of collaborative efforts between public, private, and community providers.  In particular, the roles of public health and health care workers in institutional settings are emphasized as they relate to shared community efforts.  In light of the recent outbreaks of drug-resistant disease and the associated increase in TB morbidity and mortality, the need for these partnerships is urgent.

The deteriorating public health infrastructure is having a profound effect on the ability of public health departments to continue TB control efforts in many parts of the country.  Many factors are responsible for this deterioration, including poor economic times and shifting resources to areas perceived to be more important that TB control.  Health departments have long had the will and the commitment to control this disease and prevent its transmission.  What has been lacking has been the political support at both the state and federal levels to provide resources needed to get the job done.

Q18_Recc:
Correct the above problems cited in the concluding section.  (There is a need for more political support at the state and federal levels to provide3 the necessary resources and public health services for TB control and prevention.  There is also an urgent need for more partnerships and collaborative efforts between public, private, and community providers.)


Q1_Title:
Social scientists and the new tuberculosis

Q2_Key:
TB, multi-drug resistance, social factors, compliance

Q6_ReQue:
Commonly cited factors to TB resurgence, HIV and TB strains resistant to multiple TB drugs (MDR TB) are examined along with social forces such as poverty, economic inequality, political violence, and racism.  The central thesis is that the emergence of MDR TB (and of the “new” TB epidemic in general) is inextricably linked to structural violence.  Within the article, a case study was used to illustrate the relationship between MDRTB and structural violence.

Q7_TheoBas:
N/A.  Note: Several social science (especially anthropology) and biomedical models are described though none are explicitly cited as the basis of this study.

Q9_Other:
Methods not stated.  Interviews and chart review presumably used for case study of 1 individual.

Q14_Desc:
The article examines the complex interplay of individual agency and structural violence & barriers to biomedical care.  Insights from a case study of a young Haitian man with MDR TB and from other research on TB and HIV disease are considered in light of past anthropological literature on TB.

Q15_Outc:
The patterns of  MDR TB speak to some of the large-scale social forces at work in the new TB epidemic (which predate HIV).  Social scientists often mar contributions to an understanding of TB by making “immodest claims of causality” regarding its distribution and course especially regarding the following:  conflating structural violence with cultural difference, minimizing the role of poverty, exaggeration of patient agency, romanticism about “folk healing,” and the persistence of insularity within social science sectors.

Q17_Conc:
MDR TB is a biologically and socially complex development.  To check it, we must understand the forces promoting and retarding its advance.

Q18_Recc:
Recommendations for how anthropology & social scientists might contribute to MDR TB control efforts:  1) Social scientists are best able to discern the precise mechanisms by which social forces (ranging from racism to political violence) promote or retard the transmission or recrudescence of TB; to offer a hierarchy of factors and understand how, in different settings, these might be differentially weighted.  2) Ethnographic research will be important in identifying and ranking the barriers preventing those afflicted with MDR TB from having access to the best care available.
3)  Social scientists should become more engaged in multidisciplinary research and trials.  4) Research that exposes and deplores the precise mechanisms by which entrenched medical inequities are buttressed may help to redress these inequities.


Q1_Title:
Community based approaches to the control of multidrug resistant tuberculosis:  introducing 'DOTS-plus'

Q2_Key:
multi-drug resistant TB, DOTS-plus, community based strategies

Q6_ReQue:
Goal of meeting was to assess the scope and dynamics of the emerging problem of MDTB, the strengths and limitations of existing control strategies, and the potential contribution of community based treatment efforts.

Q14_Desc:
This article presents highlights from a meeting held at Harvard Medical School, which sought to reexamine policies for controlling TB in light of new epidemiological and clinical research. Multidrug resistant TB (MDRTB) is a global pandemic, with focal “hot zones” of increased transmission. MDRTB is important cause of morbidity and mortality and not restricted to certain regions around the world.

Q15_Outc:
Although there is a key need in global control of TB to adopt DOTS, in no setting in the world with established problem of MDRTB have cases fallen when DOTS was introduced. Short course chemotherapy will not cure MDRTB. Incidence rates of TB and MDRTB have risen in Russia, Mexico, and Peru. A novel attempt – a community based effort - to treat MDRTB in Peru using directly observed, individualized treatment. With aggressive treatment the patients became smear negative.

Q17_Conc:
Clinical outcomes in the community-based effort in Peru seemed to be as good as those in US medical centers. In settings of high transmission of MDRTB, “DOTS-plus” (a complementary DOTS based strategy with provisions for treating MDRTB) is warranted. Although meeting participants expressed concern about diversions of funds to treat MDRTB, the decision to allocate scarce resources was deemed unwise and instead a larger investment in global control of TB is warranted. 
All patients with active TB, regardless of drug susceptibility patterns have a right to treatment. Resistance to TB agents is an urgent problem demanding prompt attention.

Q18_Recc:
Community based strategies designed to enhance local capacity are cost effective and make it possible to meet new medical challenges. In some settings DOTS alone is insufficient and meeting participants agreed that in hot zones, complementary measures such as technical capacity and political will are necessary for success. Thus, DOTS-plus is recommended in areas where DOTS is established or will be established. To help oversee DOTS-plus, a new WHO working group will be established with the following goals: bring new resources to TB, identify sites in which to replicate community based approaches, and provide appropriate technical assistance.


Q1_Title:
Tuberculosis, Poverty, and 'Compliance': Lessons from Rural Haiti

Q1_Author:
Farmer, P., Robin, S., Ramilus, S., & Kim, J.

Q3b_Both:
The intervention for this study was designed to address the goals of case finding, adequate chemotherapy, and close follow-up by providing several incentives that focus on improving the patients’ overall health care.

Q6_ReQue:
Does enhanced care and follow up (financial aid, incentives to attend monthly clinic, aggressive follow up at home) improve mortality and morbidity (including average weight gain after one year, ability to return to work, and cure rate) as compared to free health care alone?

Q8_SampCom:
60 (30 intervention group; 30 control group)

Q14_Desc:
The setting was the catchment area of Proje Veye Sante, Haiti.  The intervention consisted of intensive follow up with community health workers (daily visits for the first month after diagnosis); financial aid ($30 per month for 3 months); nutritional supplements; monthly reminder to visit the clinic; transportation expenses to cover travel to clinic visits; home visit by HCP for clinic appointment no shows.  

Both groups received free care at the clinics.

Q15_Outc:
Authors state that when economic factors are addressed and intensive community outreach is in place, cure rates can be improved.   Refer to Table 1 (p. 256) for list of variables measured in the study.  Note:  Cure rate for Sector 1 = 100%; Sector 2 = 56.7%

Q17_Conc:
The project suggests that a program that includes financial or nutritional aid may be far less expensive and more feasible than the TB control programs now in place in many developing countries.  It also suggests that high cure rates are possible in a setting of extreme poverty in which hospital-based care is unavailable even for the critically ill.  Data from Proje Veye Sante also imply that it is necessary to coordinate AIDS-prevention efforts with TB-control programs.

Q18_Recc:
Future programs in impoverished areas like Haiti should address underlying factors such as poverty, poor nutrition, etc. that play a major role in the control of TB.


Q1_Title:
Social vulnerability and death by infection

Q2_Key:
TB, infection, HIV, social vulnerability

Q6_ReQue:
The aim of this editorial is to comment on the social and public health impact of TB.

Q14_Desc:
Through the use of articles in the literature this editorial coveys the staggering statistics of TB prevalence and co-infection with HIV in the US and the world, at the same time commenting that results to can only be achieved through the combination of social and public health measures.

Q15_Outc:
Patients who can be identified and followed may also become subject to concerted medical care and social intervention.  An example is legalizing needle exchange programs for injection drug users.  In addition to funding and faithfully implementing the well-established protocols to find and treat cases of TB, public health authorities should open there minds to novel strategies to combat the upsurge in TB.  As an example, using vaccination with BCG for high risk persons.

Q17_Conc:
With the advent of molecular genetics and an expanded appreciation of the social determinants of disease, it may ultimately prove possible to unite knowledge of the causation of disease gained at the social, individual and molecular levels.  TB represents a prime opportunity for such a synthesis of understanding of the human susceptibility to disease.  One of the ongoing responsibilities of public health authorities must be to reach the hardest to reach and see that care is provided to those who are least cared for.  In the case of infectious diseases such as AIDS and TB, and especially in light of the prevalence of organisms resistant to multiple drugs, the health of everyone depends directly on their success.


Q1_Title:
A Preventable Outbreak of Tuberculosis Investigated through an Intricate Social Network

Q1_Author:
Fitzpatrick, L., Hardacker, J., Heirendt, W., Agerton, T., Streicher, A., Melnyk, H., Ridzon, R., Valway, S., & Onorato, I.

Q2_Key:
outbreak, TB control, social network, contact investigation

Q3a_Other:
TB outbreak and social network approaches

Q5_Other:
epidemiologic case review and contact investigation

Q6_ReQue:
This article described an outbreak investigation of TB in an urban community in Indiana.

Q9_Other:
TB logs, and clinical laboratory tests were used.

Q10_AduOth:
family members of TB cases were interviewed

Q14_Desc:
In response to a 4-fold increase in the TB cases in a city in Indiana, an outbreak investigation was conducted to assess the increase in cases and to identify possible epidemiologic links among persons with TB identified 41 active TB cases.

Q15_Outc:
Epidemiologic links and/or matching DNA fingerprints were identified for 31 of the 41 patients (76%).  The majority of these patients were members of a single social network within the community.  Links for most of these patients were identified after multiple interviews with patients and their contacts.  TB control activities in the county were limited prior to the identification of the outbreak.  At least 24 cases may have been preventable.

Q16_Limt:
Initially, the racial and cultural dissimilarities between health department personnel and the outbreak community created a barrier to TB control efforts.  Despite this obstacle, health department personnel were persistent in their attempts to communicate with the outbreak populations and increased their visibility in the community.

Q17_Conc:
This outbreak may have been prevented with prompt case identification and effective contact tracing and screening during the years before the outbreak.  This outbreak demonstrates the need for adopting novel methods of TB control.  The use of social networks should be considered in the investigation of outbreaks that involve difficult-to-reach populations.  TB control measures should be maintained in areas with historically low TB incidence.

Q18_Recc:
Initial recommendations made to the local and state health departments focused on measures that would halt the outbreak.  Because there were likely to be more active cases in the community, authors recommended continues active case finding and targeted skin testing in high-risk areas like the junkyard, including, but not limited to, local bars, corner stores, and the popular apartment complex.  Although targeted testing is intended primarily for the identification of infected person, this method can expose additional active cases of TB within the community and might prove useful in an acute outbreak setting.  The authors also recommended expanded contact investigations for persons with TB who have high percentages of infected contacts, and treatment for LTBI for persons who ha previously been screened and found to have infection with M. tuberculosis, but who were not started on therapy.


Q1_Title:
Compliance of patients and physicians: Experience and lessons from tuberculosis-I

Q2_Key:
Compliance, patients, physicians, TB, regimen, provider

Q3b_Both:
Patient adherence to medicine regimens were discussed (internal) as were the changes in regimens and related practices (external) over several decades.

Q6_ReQue:
The principal theme is physician compliance; the readiness of doctors to introduce into their practice clear cut advances established in well-conducted controlled clinical trials and surveys.

Q13_Comm:
NO mention of statistical significance/power; findings cited were from other studies.

Q14_Desc:
The purpose of this article was to report findings from clinical controlled trials and studies’ contributions to measuring TB patient compliance and physicians’ implementation of, these measures.

Q15_Outc:
Among the major advances in the past 25 [sic] years resulting from controlled clinical trials was the demonstration that admission to hospital was not necessary to treat pulmonary TB effectively.  This was already well documented in the early 1960s, particularly in the Madras study of patients and their family contacts.  This development, however, highlighted the problem of patient compliance with outpatient self-medication, which had already been recognized in the mid-1950s. A consequence was the development in the 1960s of regimens of intermittent, usually twice weekly, chemotherapy; every dose being given under full supervision.  An alternative approach, developed in the 1970s, was to shorten the duration of chemotherapy.  This became possible with the advent of rifampicin and the reintroduction of pyrazinamide into primary chemotherapy, and by the mid-1970s the effectiveness of both daily and intermittent short duration regimens was established.

Q17_Conc:
Patient compliance is an important consideration when designing controlled clinical trials, as it may greatly influence the validity of comparisons of the efficacy and toxicity of alternative regimens of chemotherapy.  The Madras study led to the development and introduction of fully supervised intermittent regimens, short duration regimens, and combination of the 2 in attempts to overcome the problems of compliance during long term self administered daily regimens in outpatients.

Q18_Recc:
Recommendations: It is important to study analyze and present compliance data from controlled trials with care and to appreciate their limitations.  It is also important to obtain information in nationally representative sample surveys for patients treated.


Q1_Title:
Compliance of patients and physicians: experience and lessons from tuberculosis-II

Q3b_Both:
The article discussed provider adherence to medicament regimen developments (internal) and ways of influencing practicing clinicians through policies (external) and other efforts.

Q6_ReQue:
The principal theme is physician compliance; the readiness of doctors to introduce into their practice clear cut advances established in well-conducted controlled clinical trials and surveys.  The clinical need to overcome the problems of self-administration of medicaments led the author to explore the efficacy and acceptability of intermittent regimens based on twice weekly or once weekly treatment with isoniazid and streptomycin and ways of influencing practicing clinicians.

Q13_Comm:
No mention of statistical significance/power; findings cited were from other studies.

Q14_Desc:
The purpose of this article was to explore the efficacy and acceptability of intermittent regimens and short course chemotherapy. Findings and implications were reported for improving TB regimen compliance and physicians’ implementation of, these measures.  (This article is part II in a series.)

Q17_Conc:
It is important to consider ways of influencing practicing clinicians to bring and keep their management, particularly treatment, of patients up to date.  As with patient compliance, it is by pooling experience from different disciplines and by combining experimental and observational approaches that we can best learn how to change the practices of clinicians rather than just informing the medical profession of recent developments and current thinking.

Q18_Recc:
Recommendations of ways of influencing practicing clinicians:
1) Dissemination of information is an essential starting point to ensure implementation. 2) Government policies, such as edicts, have much more force to change clinicians’ practices than mere recommendations.  3) Formal statements made by societies such as the American Thoracic Society.  WHO Expert Committee on Tuberculosis makes recommendations about TB control, which are widely implemented by developing countries. 4) Educational activities such as individual clinician’s lectures or reviews, which are later published, or postgraduate courses. 5) Research programs sustained over many years and based on multicenter controlled clinical trials. 6) National surveillance of clinicians’ actual practices.


Q1_Title:
Screening of Physicians for Tuberculosis

Q1_Author:
Fraser, V., Kilo, C., Bailey, T., Medoff, G., & Dunagan, W.

Q1_Journal:
Infection Control and Hospital Epidemiology

Q6_ReQue:
To determine the prevalence of TB infection among a sample of physicians at Barnes Hospital and to determine the frequency of tuberculin skin testing and the adequacy of follow-up for physicians with positive tuberculin skin tests.

Q14_Desc:
Physicians attending departmental conferences were screened for TB.  Prior history of TB, anti-TB therapy, BCG vaccination, and previous tuberculin skin test results were obtained with a standardized questionnaire.  Tuberculin skin tests were performed on those who were previously skin test negative.

Q15_Outc:
86 (24.5%) of 351 physicians in the study were skin test positive by history or currently performed skin test.  Of 61 who reported a previously reactive skin test, 40 (66%) had been eligible for INH prophylaxis, but only 15 (37.5%) of 40 had completed at least 6 months of therapy.  Of 290 physicians reporting a previously negative skin test, 25 conversions (8.6%) were identified.  Previous undiagnosed, asymptomatic pulmonary TB was identified in 1 physician.

Q16_Limt:
There are several limitations to this study.  By not performing two-step testing, some of the positive skin tests we identified may not be conversions but rather boosted reactions due to distant TB exposures.  In addition we defined positive TST as 10 mm of induration since we were not able to document an increase of 10 mm induration from previous skin tests.  Selection bias may have influenced the rates as well since those who perceived themselves to be at risk for TB may have been more likely to participate.

Q17_Conc:
Infection with M. Tuberculosis is common among physicians.  Physicians were screened irregularly for TB, and the use of prophylactic therapy was inconsistent.  Aggressive TB screening programs for healthcare workers should be instituted.


Q2_Key:
United States, active disease, TB control

Q6_ReQue:
Argument:  During the past eight years, cases of active tuberculosis have increased substantially in the United States and other industrialized countries.  This increase was caused by the following:  the spread of tuberculosis in such congregate settings as hospitals, shelters, and correctional facilities; a declining public health infrastructure; immigration from areas of the world where tuberculosis remains endemic; and the human immunodeficiency virus (HIV) epidemic.

Q9_Other:
Reviews of other articles published in the American Journal of Public Health

Q14_Desc:
The author gives a broad overview of tuberculosis control programs in the United States, and cites four articles (all published in that same issue of the American Journal of Public Health) that address the challenges and priorities of modern tuberculosis control.

Q15_Outc:
The authors argues that there is little or no public health value in identifying persons who have tuberculosis infection or disease if complete treatment cannot be offered.  Although socioeconomic improvements can decrease tuberculosis incidence, effective tuberculosis control programs can reduce tuberculosis incidence even faster.  In the United States today, even in underserved communities, most active tuberculosis cases are known; therefore, rather than directing our efforts at case finding, we should direct our efforts at ensuring that patients with active disease complete their treatment and at finding high-risk infected persons and ensuring that they complete preventive therapy.

Q18_Recc:
As the disease once again begins to decline in the United States and leaves the front pages, our challenge will be to persevere.  We must expand effective outreach programs such as those described by Leonhardt et al., provide services to underserved populations such as those described by Ciesielski et al., target services to groups identified by epidemiological studies such as the study by Buskin et al., conduct the epidemiologic investigations called for by Comstock, and work to improve the social and economic environment that provides the substrate for the tuberculosis epidemic in the United States and abroad.


Q1_Title:
Psychosocial Issues in the Management of Patients with Tuberculosis

Q1_Author:
Fullilove, M., Young, R., Panzer, P., & Muskin, P.

Q3b_Both:
This article discusses a variety of issues that pertain to both domains, such as the mental health and psychosocial problems of TB patients; migration and acculturation issues; and housing issues and the health care

Q6_ReQue:
To show that mental health and other psychosocial problems deserve considerable attention in the early stages of designing TB treatment programs.

Q14_Desc:
The purpose of the article was to present selected case histories of hospitalized tuberculosis patients seen for psychiatric consultation.  The study consisted of 27 cases and 27 controls.  (Note: The report did not compare the cases and controls.)  The data that was abstracted from the chart reviews included demographic data, reason for psychiatric consultation, psychiatric diagnosis, special issues for the consultation, such as competence and need for surveillance, and history of tuberculosis, including medication compliance.

Q15_Outc:
The heterogeneity of both diagnoses (TB and other psychiatric disorders) and possible interventions argues against the simple use of formula-driven algorithms to guide patient care.  A systems approach, which includes psychological and social factors contributing to problematic behavior, was the most efficacious.

The social support available to the patient is critically important in promoting compliance with isolation orders.  Some of the social barriers to patient compliance in treatment include family indifference or ignorance, clinicians’ pessimism or aversive interpersonal style, and poorly coordinated, unpleasant treatment settings.

Careful assessment of the individual’s belief systems is critical in making correct judgments about treatment.

People need to be free of a daily struggle for shelter so that they can attend to other tasks of self-care.

Q17_Conc:
Psychosocial problems are common among hospitalized TB patients.  A treatment system capable of individual assessment and wide-ranging psychosocial interventions is likely to have a dramatic effect on noncompliance among the most vulnerable TB patients.

Q18_Recc:
1) Patients with mental health problems need a full evaluation that takes into consideration individual, social and cultural factors that may interfere with the patient’s ability to complete a prolonged course of therapy.  2) Realistic treatment of TB will depend on the development of systems that can address the full range of problems presented by the individual, including psychiatric illness, housing, social attachments, and other medical problems.


Q1_Title:
The Use of Legal Action in New York City to Ensure Treatment of Tuberculosis

Q1_Author:
Gasner, M., Maw, K., Feldman, G., Fujiwara, P., & Frieden, T.

Q2_Key:
TB, directly observed treatment, compliance, adherence, legal, detainment

Q6_ReQue:
We evaluated the first two years of the regulatory program, focusing on the use of detention and less restrictive measures to ensure the completion of treatment and the risk factors for detention.

Q8_SampCom:
328 legal orders issued; 304 legal orders issued and confirmed TB

Q13_Comm:
: p < .05 for significance, Chi-square test and logistic regression (Odds Ratios, CI) were used.

Q14_Desc:
After an increase in the number of cases of TB, New York City passed regulations to address the problem of nonadherence to treatment regimes.  The commissioner of health can issue orders compelling a person to be examined for TB, to complete treatment, to receive treatment under direct observation, or to be detained for treatment.  On the basis of a review of patients’ records, we evaluated the use of these legal actions between April 1993 and April 1995 to determine the risk factors for detention and the factors for adherence.

Q15_Outc:
Among more than 8000 patients with TB, regulatory orders were issued for less than 4%.  Among patients with a variety of social problems only a minority required regulatory intervention.  A total of 150 patients were ordered to undergo directly observed therapy, 139 patients to be detained during therapy, 12 to be examined for TB, and 3 patients to complete treatment.  Repeatedly noncompliant patients and those who left the hospital against medical advice were more likely than others to be detained.  The median length of detention was 28 weeks for noninfectious patients.  As compared with patients ordered to receive directly observed therapy, the patients who were detained remained infectious longer, had left hospitals against medical advice more often, and were less likely to accept DOT voluntarily.  Altogether, excluding those who died or moved, 96% of the patients completed treatment and 2% continued to receive treatment for MDR-TB.

Q16_Limt:
Because information on adherence for the entire group of patients with TB was not available, we cannot prove that every patient who was repeatedly noncompliant with therapy was subject to regulatory action and there was no bias in issuing orders.

Q17_Conc:
For most patients with TB, even those with severe social problems, completion of treatment can usually be achieved without regulatory intervention.  Patients were detained on the basis of their history with TB, rather than on the basis of their social characteristics, and the less restrictive measure of mandatory directly observed therapy was often effective.


Q1_Title:
A Study on Knowledge and Attitude Towards Tuberculosis in a Rural Area of West Bengal

Q1_Author:
Gehtakrishnan, K., Pappu, K.P., & Roychowdeury, K.

Q2_Key:
Tuberculosis, TB knowledge, medical knowledge, social attitudes, and West Bengal, India

Q6_ReQue:
The objective of the study was to determine the “level of general knowledge and awareness about TB and to find out the prevalent social attitudes towards the disease.”

Q8_SampCom:
50 heads of households from the sampled villages, 10 community leaders, 60 patients, and 213 community members were interviewed

Q13_Comm:
The specific tests used to determine rejection or acceptance of the null hypotheses are not described in detail.

Q14_Desc:
The article describes a health services survey of general TB knowledge, knowledge about the general medical management of the disease, and social attitudes towards TB in rural areas of West Bengal, India.  General TB knowledge was assessed through questions such as “Is tuberculosis a hereditary disease?” and “Is haemoptysis the main symptom in tuberculosis?”.  Medical management questions included items about the duration of treatment, necessity of hospitalization and isolation, diet, etc.  Attitudinal items included those such as, “Can a completely cured TB patient marry?” and “Would you negotiate marriage for your Son/Daughter with an ex-TB patient?”

Q15_Outc:
The authors highlight several of the general results, including: (1)“General knowledge about TB is high in both groups.” (2) As much as 24% of new patients did not know the correct duration of treatment.” (3) “The majority of people interviewed were in favor of hospitalization of the TB patients.”  The research indicated that social attitudes still hold high levels of stigma and that “the TB patient is still a social ‘untouchable’.”  Additionally, differences in knowledge were found between those who’d been exposed to health education and those who had not, with no differences found based on literacy.

Q17_Conc:
The authors suggest two specific conclusions.  First, despite community leaders having better knowledge about the disease, social attitudes are not affected.  The authors suggest efforts to actively involve these leaders in TB control programs.  Second, the authors conclude that health education “has a positive impact on a TB control program.”  Although stigma remains, the authors contend that further awareness will likely facilitate a desired change in social attitudes.

Q18_Recc:
In addition to the above, the authors call for additional resources to be spent on social aspects of tuberculosis.


Q1_Title:
Tuberculosis in physicians: Compliance with preventive measures

Q2_Key:
TB, compliance, physicians, preventive measures

Q6_ReQue:
We evaluated the compliance with public health recommendations for the control of TB in health care workers by a survey mailed in 1982 to physicians who had graduated medical school between 1938 and 1981.

Q8_SampCom:
7420 total surveys sent => 4505 responded

Q11_USA:
US (states not specified):  national survey

Q14_Desc:
Compliance with public health recommendations for TB control was evaluated by a survey of 4417 physicians who had not contracted TB during medical school nor during the 4 decades after graduation through 1981.

Q15_Outc:
31% of the cohort had been vaccinated with BCG and 47% considered themselves tuberculin-positive.  32% of 1088 physicians who graduated after 1974 had been exposed to 3 or more patients with infectious TB in the previous year.  58% of 738 unimmunized, tuberculin-negative physicians who had been exposed to 1 or more patients with infectious TB in the previous year had a tuberculin test every 1 to 2 years.  49% of 597 unimmunized tuberculin reactors with similar occupational exposure had chest roentgenograms every 1 to 2 years.  The BCG-vaccinated physicians were less likely to have frequent tuberculin tests but no different frequency of chest roentgenograms.  8% of 1460 unimmunized tuberculin reactors received INH chemoprophylaxis, including 39% of 128 tuberculin reactors who graduated after 1974 (the majority of the latter were younger than 35 years of age).  0f 66 physicians who had active TB during medical school of after graduation, 20 (30%) had not received any anti-TB chemotherapy, whereas 2 of 46 who did, received chemotherapy only after a second episode of TB.

Q16_Limt:
The reliability of self-reporting of tuberculin reactions in this cohort could not be assessed.

Q17_Conc:
In summary, this study documents poor compliance by physicians with recommended policies for the prevention of TB in health care workers and considers a reevaluation of the current indications for BCG vaccination in physicians and health care workers.


Q1_Title:
Controlling Resurgent Tuberculosis: Public Health Agencies, Public Policy, and Law

Q1_Journal:
Journal of Health Politics, Policy, and Law

Q2_Key:
TB, public health, health agencies, law, policy

Q6_ReQue:
The purpose of this article is to critically examine the conventional wisdom regarding what public health agencies should do to combat TB and how their capacity to combat it an be enhanced.

Q14_Desc:
In this article the author deals with public policy and legal issues related to the role of the public health authorities in controlling the resurgence of TB.  The article begins with a description of the nature and extent of the current TB problem and go on to consider three interconnected issues with respect to public health TB control measures: the formulation and implementation of effective measures, the use of governmental coercion to enforce these measures, and a comparison of public health approaches to HIV control and to TB control.  Then discuss the need to rebuild the public health infrastructure in order to foster and facilitate effective TB control efforts in particular and communicable disease control efforts in general.  Finally, some observations on the need to link public health TB control efforts with other efforts that address the economic and social problems that underlie the resurgence of TB and that may contribute to future epidemics of serious communicable diseases.

Q15_Outc:
In devising a strategy to prevent the spread of TB, public policy makers must adapt traditional TB control measures to reflect the current problem.  Such a strategy can and should include the appropriate use of governmental coercion to compel observance of public health TB control measures.  Public health approaches to control HIV, with their emphasis on the voluntary cooperation of those infected and at high risk for infection, are not a model for effective TB control.  Additional resources, while needed, will not alone enable public health agencies to bring TB and other communicable diseases under control.  In the present debate over health care reform, little attention has been paid to the importance of public health agencies in protecting the public health.

Q17_Conc:
TB’s return signals the importance of confronting the social and economic problems that enormously complicate effective TB control.  Public health officials should play a leadership role in developing systems that are comprehensive, coordinated, and community-based to meet the multiple needs of TB high risk groups, and public policies should be put in place that address the social and economic problems underlying the TB problem.


Q1_Title:
Successful Adherence to Observed Prophylaxis and Treatment of Tuberculosis Among Drug Users in a Methadone Program

Q1_Author:
Gourevitch, M., Wasserman, W., Panero, M., & Selwyn, P.

Q2_Key:
TB, directly observed treatment, prophylaxis, adherence

Q6_ReQue:
Does a program of voluntary, directly observed prophylaxis and treatment of TB in an inner city substance abuse treatment program with onsite medical care improve patient adherence?

Q8_SampCom:
114 (102 – Chemoprophylaxis; 12 – Treatment)

Q14_Desc:
Incomplete anti-TB chemoprophylaxis and treatment are major causes of the resurgence of TB, often drug-resistant, among drug users.  We offered directly observed anti-TB chemoprophylaxis (n=102) or treatment (n=12) to eligible methadone maintenance treatment patients methadone dosing was not contingent upon ingestion of anti-TB medication(s).  No material incentives were provided.

Q15_Outc:
90 (88%) prophylaxis and 9 (75%) treatment patients were administered ≥ 5 weekly doses of anti-TB medications during ≥ 80% of 4740 patient weeks.  The majority of patients were HIV-seropositive.  Active substance abuse was not associated with diminished adherence.  Over 80% of patients completed or were still receiving therapy at the end of the study.

Q16_Limt:
Longer periods of follow-up upon completion of prophylaxis are required before firm conclusions regarding the efficacy of prophylaxis may be reached.  We were not able to compare the rates of adherence and completion described in this study to those prior to institution of directly observed chemoprophylaxis and treatment in our program.

Q17_Conc:
Adherence to and completion of directly observed antituberculous therapy can thus be attained by drug users in treatment, despite ongoing drug misuse.  Substance abuse treatment programs provide opportunities for enhanced compliance, and should thus be viewed as critical components of strategies to address the TB epidemic in drug users.


Q1_Title:
DOTS and beyond: towards a holistic approach to the conquest of tuberculosis

Q3b_Both:
The editorial discusses internal influences such as local belief systems as well as external domains such as quality of medical services and adequate drug supply.

Q6_ReQue:
The editorial critiques the World Health Organization’s announcement of a breakthrough in TB control (i.e., directly observed treatment, short course (DOTS)), and makes the case for a holistic approach to TB control.

Q14_Desc:
The editorial is a critique of DOTS and TB control failures.  The article makes the case for a more holistic understanding of barriers to TB control and the need for a holistic approach to TB control.

Q15_Outc:
The WHO press release caused concern and misgivings among TB workers for 2 principal reasons:  1) fear that such an announcement would prove a disincentive to global and national funding bodies to support basic research that is urgently required to provide highly reliable diagnostic tools, better vaccines, and novel therapeutic regimens; 2) DOT, in various forms, has been known and practiced for many years and that merely giving it an eye-catching acronym is a far cry from ensuring its widespread and successful deployment.

Q17_Conc:
The conquest of TB demands a truly holistic approach.  Ultimate success requires a range of human activities from elucidating the basic molecular structure of the genome of the tubercle bacillus to attending to the major global issues of peace and justice.

Q18_Recc:
Several TB control recommendations were made:  
•patient identification efforts require careful attention to mircroscopy diagnostic services; 
•health education must communicate at the patient’s level of understanding;
•adherence requires a caring relationship between patient and caregiver;
•health care providers need attention to their job satisfaction & remuneration;
•treatment requires regular supply of quality drugs at no cost to patient;
•spiritual dimension of medical care should be addressed, e.g., involving religious groups and understanding the mind-body-spirit connection; and
•wider international commitment to reducing economic inequalities.


Q1_Title:
Tuberculosis in Prison: Balancing Justice and Public Health

Q1_Author:
Greifinger, R., Heywood, N., & Glaser, J.

Q2_Key:
TB, prison, public health, justice, policy

Q6_ReQue:
A renewed public health crisis provides an opportunity to renew the rationale, and address the issue of communicable disease control in prison.  It also provides the occasion to assert that public purpose is poorly served when inmates are subjected to unnecessary and arbitrary indignities.  It is better served when communicable disease control is consistent with prudent public policy.

Q14_Desc:
Recent reports of primary infection with TB, progressing rapidly to active and contagious disease, have sounded a public health alarm.  The danger becomes more clear as the magnitude to the free-world population is added to the threat to those incarcerated, and the danger of TB is calculated in a setting with a high prevalence of HIV.  The resurgence of TB demands that we broaden the perspective of prison health to include public health challenges to meet public health opportunities.  This will serve to benefit the inmates themselves, the correctional workforce and the community at large.  These opportunities can be seized for public purposes while maintaining respect for individual rights.  Individual medical care in prison has received increased attention.

Q15_Outc:
Public reaction about the public health issues within the New York State correctional system served a useful purpose, creating a large educational program and mandatory skin testing program for employees.  Management of infection control programs (surveillance) requires accurate and timely information of the incidence and prevalence of infection.  Without this it is difficult to have effective programs to prevent transmission of the disease.  Prevention therapy with INH is recommended, but there are several implications for inmates that make preventative therapy impractical and perhaps dangerous.  However if preventative therapy is initiated it is critical to maintain vigilance to continue uninterrupted therapy.  Mandatory HIV testing and HIV status would not serve to protect against TB transmission.

Q17_Conc:
Humane correctional policy and the Constitution both require medical care for inmates.  This care can also serve a broader social and public health purpose.  There are clear benefits for the communities to which the inmates return when individual care and public health are both addressed by correctional health services.  Correctional health is unique by virtue of the nature of criminal justice institutions, but can serve as a useful prototype for other settings.  The adoption of proven infection control policies and environmental remedies provides a direct public service to a community that extends well beyond the walls of the institution.  But these programs must be carefully considered and recognize the civil rights of inmates.


Q1_Title:
Ecological analysis of ethnic differences in relation between tuberculosis and poverty

Q1_Author:
Hawker, J., Bakhshi, S., Ali, S., & Farrington, C.

Q2_Key:
TB, race, ethnicity, poverty, deprivation

Q6_ReQue:
The objective of this study was to examine the effect of ethnicity on the relation between TB and deprivation.

Q10_AduIntl:
British White, South Asian, Black, Caribbean

Q10_ACIIntl:
British White, South Asian, Black, Caribbean

Q14_Desc:
A retrospective ecological study comparing incidence of TB in white and south Asian residents of the 39 electoral wards in Birmingham with ethnic specific indices of deprivation was performed.  Details of notifications of TB in Birmingham for the five years 1989 to 1993 were obtained from the Birmingham TB notification register.  1991 census data was used as the denominator to calculate specific mean annual notification rates.

Q15_Outc:
Univariate analysis showed significant associations of TB rates for the whole population with several indices of deprivation (see article) (P< 0.01) and with the proportion of the population of south Asian origin (P< 0.01).  All deprivation covariates were positively associated with each other but in multiple regression, higher level of overcrowding was independently associated with TB rates.  For the white population, overcrowding was associated with TB rates independently of other variables (P< 0.0036).  No relation with deprivation was found for the south Asian population in either single or multivariable analyses.

Q16_Limt:
Caution is needed when drawing conclusions about causation from ecological studies as they may not properly reflect association at the individual level because of confounding or modification of effect.  In addition, regression analyses depend on the estimates of TB rates in each ward, and although this study contains 4 to 15 times as many cases as previous studies, some of the ethnic ward rates are based on small numbers of cases.

Q17_Conc:
Poverty is significantly associated with TB in the white population, but no such relation exists for those of Asian ethnicity.  These findings suggest that causal factors, and therefore potential interventions, will also differ by ethnic group.  An increasing proportion of TB is occurring in Asian people and causal factors in this group are likely to be different from those in the white population.

Q18_Recc:
Further research is necessary, including a case-control study to disentangle the confounding effects of poverty, ethnicity, and age at the individual level.  In addition, recent developments in DNA analysis of M. tuberculosis could be used to study patterns of transmission within and between ethnic groups.


Q1_Title:
Health Locus-of-Control Beliefs in Vietnamese Clients with Latent Tuberculosis

Q2_Key:
health beliefs, Vietnamese, latent tuberculosis

Q6_ReQue:
What are the associations between age and gender and health locus of control for Vietnamese clients receiving preventive therapy for latent tuberculosis?

Q7_TheoBas:
What are the associations between age and gender and health locus of control for Vietnamese clients receiving preventive therapy for latent tuberculosis?

Q14_Desc:
The purpose of this study was to examine the health locus-of-control beliefs of the Vietnamese and their associations with age and gender.  The data was collected from a larger study on Hispanic and Vietnamese explanatory models of illness and compliance with a TB prevention therapy program.  The Multidimensional Health Locus of Control (MHLC) scale was used to measure beliefs in control by the self (internal), chance, or powerful others.

Q15_Outc:
Internal-locus clients scored highest overall.  Males scored significantly higher on external “powerful other” locus of control than females.

Q16_Limt:
Convenience sampling was used to include as many clients as possible within the time frame available for the larger study.  A number of clients declined to be interviewed.  Also, the data collection instrument was simplified to two options, which decreased the tool’s sensitivity.

Q17_Conc:
Health care professionals (e.g., nurses) who use a culturally sensitive teaching approach and protocol, together with Vietnamese clients, could initiate a decline in the rate of Asian TB in the US.

Q18_Recc:
A strong internal health locus of control in Vietnamese clients and acknowledgment of powerful others by the family decision maker, will be beneficial in the arena of changing health care providers and the US health care infrastructure.  Health education is needed for each family member, especially the women because they are usually the caretakers of both sexes.

It would be useful to further study which cultural attributes and characteristics enhance compliance with preventive TB therapy.


Q1_Title:
Tuberculosis programmes:  fragmentation or integration?

Q6_ReQue:
Hypothesis:  What is needed in most tuberculosis programs is a fruitful symbiosis of specialized knowledge and specific program elements that go hand-in-hand with the efficient utilization of an integrated health care system including functioning and community-based primary health care.

Q14_Desc:
There is an ongoing discussion in health circles about the “vertical” versus “horizontal” approach to diseases or health projects and programs.  This editorial makes an argument against a mutually exclusive approach to tuberculosis, and calls a joining of specialized knowledge and specific program elements that go hand-in-hand with the efficient use of an integrated health care system including functioning and community-based primary health care.

Q15_Outc:
There are examples of national tuberculosis programs with a functioning combination of special leadership input based on experience with the disease and availability of earmarked resources for tuberculosis control, utilized within a general health care system based on a primary health care approach.  In Figure 2 (page 2), the author shows how a population is reached in an integrated, horizontal fashion by the local and the district level health workers, who are supported by vertical interests at regional and national levels.  At the national level there is a tuberculosis coordination unit waving the flag of specialized knowledge and with access to resources specifically allocated for tuberculosis control.  This national unit is, of course, related to other parts of the health service but has its own “flag” and administrative identity.

Q17_Conc:
A disease with important social dimensions such as tuberculosis cannot be tackled responsibly and in the required longer term, unless we learn to develop the appropriate models of integration, while at the same time applying special knowledge and resources related to the disease.  One must be ready to discard the fragmented approach (Figure 1) and ready to develop “the crown of life” approach (Figure 2).  The latter is more complex and requires much negotiation, supportive supervision, and continuous concern for functioning human and administrative relationships.

Q18_Recc:
Refusing the simplified and mutually exclusive vertical or horizontal approaches, a national tuberculosis program needs to accept the complex method of special professional competence with earmarked resources permeating the different levels of the general health care system of an integrated manner.


Q1_Title:
The Influence of Program Acceptability on the Effectiveness of Public Health Policy: A Study of Directly Observed Therapy for Tuberculosis

Q2_Key:
TB, directly observed therapy, evaluation, program acceptability, decision analysis, patient adherence

Q6_ReQue:
This study examines how patient acceptability influences the effectiveness of directly observed therapy (DOT) for tuberculosis.

Q14_Desc:
This study examined how program acceptability influences the effectiveness of self-administered therapy, directly observed therapy (DOT), and confinement in getting patients with active TB to seek, initiate, and successfully complete treatment.  A survey of 10 US directly observed therapy programs in the U.S. was conducted, finding that 67% to 95% (weighted mean: 77%) of patients in such therapy complete treatment.  Decision and sensitivity analysis were used in assessing influences.

Q15_Outc:
If mandatory DOT discourages 6% of initial TB patients (range: 4% to 10%) from seeking care, then such therapy will be less effective than self-administered therapy.  DOT is more effective than repeated self-administered therapy for patients failing to complete initial treatment unless 32% (range: 27% to 38%) of patients avoid seeking care.

Q17_Conc:
Patient acceptability must be taken into consideration before selecting public health strategies such as DOT versus self administered therapy.  As this analysis demonstrates, program acceptability is important in determining overall program effectiveness.


Q1_Title:
Migratory Journeys and Tuberculosis Risk

Q2_Key:
Chinese immigrants, New York City, illegal migration, Chinatown

Q3b_Both:
Internal domains include individual testimonies about the processes of migration, and personal beliefs about the development of TB disease.  External domains include discussions about migratory processes and their effects on TB development.

Q6_ReQue:
Objective:  This article questions the biomedical explanation of immigrant tuberculosis as being imported from immigrants’ countries of origin.

Q8_SampCom:
60 Patients at DoH chest clinics or DOT programs

Q14_Desc:
This article presents a theme from illness narratives, gathered from 60 patients at the DoH chest clinics or DOT program.  In contrast to the explanations of public health workers and Chinatown health providers who assume that Chinese patients were infected in China, patient informants discuss at length how living and working conditions in New York City contributed to their contracting tuberculosis.  Furthermore, illness narratives of a particular group of Chinese immigrants differ from others.  They point out that the illegal migration from China to the United States can render immigrants vulnerable to tuberculosis.  These informants are illegal laborers from Fujian Province.

Q15_Outc:
This article presents narratives of Fuzhounese patients who consider their illegal passage to the United States to be the cause of their sickness.  Three environments were identified that expose illegal immigrants to tuberculosis:  (1) modes of transportation across land and sea; (2) holding places such as duck buildings in transit countries or, in the United States, safe houses; and (3) detention centers.  

Designating immigrants as importers of tuberculosis appears to be a natural tendency in the maintenance of cultural boundaries.  However, the consequences of this universal tendency to blame others need to be examined.  There are several adverse implications of blaming immigrants for tuberculosis:
1) First, by suggesting that immigrants constitute a risk group, all immigrants are stereotyped as potential tuberculosis carriers.
2) Second, different countries have different patterns of immigration.  Even among immigrants from a single country such as China, a vast country with diverse regional cultures, there are different kinds of migration such as voluntary, involuntary, legal, and illegal.  We need to unpack the concept of “the Chinese” as a public health category.
3) Further, most public health discourses on tuberculosis do not differentiate between the immigrants’ countries of origin. 
4) An adverse consequence of blaming immigrants for TB is that the concept of risk puts responsibility at the level of the individual.  This stress on personal risk emphasizes that individuals must learn to take responsibility for minimizing their own risk and diverts attention away from macro-level forces shaping the spread of TB.

Q17_Conc:
In conclusion, using patient narratives and anthropological analysis of risks, this article challenges the dominant biomedical explanation of immigrant tuberculosis as being imported from immigrants’ country of origin.  The narratives suggest that Chinese laborers often are at as great a risk of tuberculosis en route to or in the United States as they are in their home country.  Anthropological perspectives on risk ultimately question the scientific approach for its neglect of the social and cultural contexts in which risk is understood and negotiated.  An alternative explanation for tuberculosis among immigrants, one that includes their migratory journeys, might avoid some of the unfavorable consequences of the dominant biomedical explanation.


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

Q1_Author:
Hong, Y., Kwon, D., Kim, S., Chang, S., Kang, M., Lee, E., Moon, H., & Lew, W.

Q2_Key:
Korea, general practitioners, attitudes, practices, knowledge

Q6_ReQue:
Objective:  To investigate the knowledge, attitudes, and practices of general practitioners in Korea on the prevention and treatment of tuberculosis.

Q12_Oth:
Korean Institute of Tuberculosis of the Korean National Tuberculosis Association

Q14_Desc:
The authors conducted a representative sample survey of the knowledge, attitudes, and practices of general practitioners in Korea surrounding tuberculosis.  Questionnaire surveys were given to 923 private general practitioners through 29 health centers.  The interview schedule was divided into two categories:  the first category for all subjects, and the second for those who treat tuberculosis patients.  Those in the first category were asked about (1) their general idea of the magnitude of the tuberculosis problem in Korea; (2) mode of transmission; (3) BCG vaccination; (4) their opinion of the NTP; (5) diagnostic method and treatment monitoring; (6) regimens employed; (7) health education of the patients; (8) notification; and (9) manner of updating information and knowledge of tuberculosis.

Q15_Outc:
Forty-nine percent of GPs considered that the Korean tuberculosis situation is not serious.  Fifty-four percent were worried about infection from patients.  Forty-seven percent answered that BCG vaccination caused untoward reactions with no or limited effectiveness.  Forty-seven percent considered the National Tuberculosis Program (NTP) unfavorably.  Over 50% did not consider sputum examination essential in case finding/diagnosis, and 75% did not consider it essential in monitoring treatment responses.  For initial treatment of active tuberculosis, only 11% were prescribing the current Korean NTP’s six-month standard regimen.  Seventy-three percent were giving currently non-recommendable regimens, and 16% unacceptably bad regimens.  However, this situation could be improved, as 80% of GPs expressed the wish to acquire knowledge.

For notification of new patients to the health authority, only 50% answered that they did.  Physicians were equally divided regarding their reasons for not notifying new cases:  100 were not aware that tuberculosis is a notifiable disease, and 100 did not notify new patients to the health authority because of the intricate paperwork.

Q16_Limt:
Fifty percent of the GPs treating tuberculosis patients answered that they notify all cases to the health authority.  However, this rate exceeds the current practice and it is possible that the rate is biased because HC personnel carried out the interviews.

Q17_Conc:
The epidemiological situation of tuberculosis in Korea is still serious when compared to those of similar Asian countries.  However, about 60% of GPs considered that tuberculosis was no longer a serious problem in Korea.  This finding suggests that their attitude may hamper current and future efforts for the control or ultimate eradication of tuberculosis in this country.  Intensive public relations and continuing education are necessary.

Q18_Recc:
Almost all GPs were allegedly giving health education to the patients at the beginning of treatment.  However, the contents and the time taken are not known.  Simple guidelines for health education may be helpful.  Knowledge of information on tuberculosis had allegedly been gained mainly through textbooks or periodicals.  80% of general practitioners answered that they need further education in various fields and mostly through booklets, followed by a continuing education program.  A simple booklet should be devised and distributed to GPs to provide clear information on tuberculosis treatment and prevention.


Q1_Title:
Marketing tuberculosis prevention programs to foreign-born Vietnamese: The role of culture in the effective diffusion of public sector health care services

Q1_Journal:
Journal of Nonprofit and Public Sector Marketing

Q2_Key:
Diffusion of innovations, public sector health care organizations, Vietnamese immigrant consumers, cross-cultural health care marketing, consumer behavior.

Q6_ReQue:
What role does culture play in the diffusion of government-administered TB prevention programs among Vietnamese immigrants.

Q7_TheoBas:
The research question is based within the framework of diffusion of innovation theory, while the qualitative component of the methodology is based in grounded theory.

Q8_SampCom:
Phase I:  8 focus groups (53 participants) and 14 key informant interviews.  Phase II consisted of 510 CATI respondents.  (Phase I data collection used non-probability sampling; Phase II data collection used probability sampling.)

Q14_Desc:
The article reports on preliminary data from a long-term project to investigate “cultural barriers that present daunting challenges to the multitude of public, non-profit, and sometimes private health care organizations attempting to meet the diverse needs of recent immigrants.”  Specifically, the article focuses on the cultural variables influencing the diffusion of TB-related messages among Vietnamese immigrants in southern California.  The research triangulates the results of focus group discussions, key informant interviews, and a telephone survey component to address the research question.

Q15_Outc:
The author presents several main themes to the perceptions of the respondents “identified during the qualitative phase and confirmed during the quantitative phase.”  Among these are the culture-based definitions of good and poor health that integrate physical health with psychological health, the distinction between “light illness” and “serious illness” (characterized primarily by duration of illness and length of recovery), and the perceptions of tuberculosis.  

In terms of the respondents’ perceptions of TB, several noteworthy findings emerged.  The majority of respondents (87.8%) saw TB as a “serious illness with dire consequences.”  The most important finding, however, is the perception held by, 82.4% of respondents that there are two distinct types of TB (physical tuberculosis and psychological tuberculosis) with distinctly different symptoms, causes, and treatments for each.

Where “physical TB” is viewed as being caused by “working too much,” “poor health,” or “tobacco smoking”; “psychological TB” is thought to come from “stress and worrying,” “depression,” or lack of adequate sleep.”  The author cites as alarming the fact that while all of the above causes are endorsed by over 85% of all respondents, only 41% feel that airborne transmission of microbes cause “psychological TB” and only 57% understand  physical TB to be transmitted in that manner.

Q17_Conc:
In terms of the health beliefs of foreign-born Vietnamese, the author concludes that there are “considerable differences between the assumptions of the innovator (the public sector health care organization) and those of the adopter (the foreign-born Vietnamese consumer).”  In terms of the cultural barriers to diffusion of TB prevention in the public sector, the author concludes that both the view of health in a holistic manner (viewing mental and physical health as inextricably linked) and the dual nature of the perceptions of TB itself could be potential barriers to diffusion.

Q18_Recc:
The author indicates that the “results of this study provide strong support for the utility of diffusion of innovations theory in the marketing of tuberculosis prevention programs by government health care agencies to foreign-born Vietnamese consumers.”  Furthermore, recommendations are made to incorporate these findings into future health promotion efforts and diffusion strategies.


Q1_Title:
Gender differentials in tuberculosis: The role of socio-economic and cultural factors

Q2_Key:
TB, socio-economic status, cultural factors, gender

Q3b_Both:
Specific health- seeking behaviors (internal) as well as socio-economic and cultural factors (external) were discussed.

Q6_ReQue:
This paper reviews current knowledge about the role that socio-economic and cultural factors play in determining gender differentials in TB and TB control.

Q14_Desc:
The purpose of this paper is to systematically review the English language literature to determine current knowledge about the role that socio-economic and cultural factors play in determining gender differentials in TB and TB control.  This review attempts to explore how socio-economic and cultural factors may lead to male/female differentials in TB and TB control.

Q15_Outc:
The literature reviewed in this paper suggests the following:  Gender differentials in social and economic roles and activities may lead to differential exposure to TB bacilli.  The general health/nutritional status of TB-infected persons affects their rate of progression to disease.  In areas where women’s health is worse than men’s (especially in terms of nutrition and HIV status), women’s risk of disease may be increased.  A number of studies suggest that responses to illness differ in women and men, and that barriers to early detection and treatment of TB vary (and are probably greater) for women than for men.  Gender differences also exist in rates of compliance with treatment.  The fear and stigma associated with TB seems to have a greater impact on women than on men, often placing them in an economically or socially precarious position.  Because the health and welfare of children is closely linked to that of their mothers, TB in women can have serious repercussions for families and households.

Q17_Conc:
The studies reviewed suggest that socio-economic and cultural factors may be important in two ways: first, they may play a role in determining overall gender differences in rates of infection and progression to disease, and second, they may lead to gender differentials in barriers to detection and successful treatment of TB.  Both have implications for successful TB control programs.  The review points to the many gaps that exist in our knowledge and understanding of gender differentials in TB and TB control, and argues for increased efforts to identify and address gender differentials in the control of TB.

Q18_Recc:
Studies aimed at describing the epidemiology of TB should investigate gender differentials in social and economic roles and activities that may lead to differential exposure to TB bacilli.  Gender inequalities of health in developing countries must be examined and addressed as an integral part of the economic, social, and cultural contexts in which they occur.  Unequal access to health care is only one manifestation of more general gender inequity in society.  No interventions studies have been conducted to specifically address gender differentials in TB control.  Finally, basic research is needed to describe the differential impact of TB on women, men and their families.

Gender inequalities of health in developing countries must be examined and addressed as an integral part of the economic, social and cultural contexts in which they occur.  Strategies to reduce inequalities must include efforts to improve the status of women.  

Potentially relevant interventions for addressing gender differentials in tuberculosis control were identified, but their effectiveness has not yet been rigorously evaluated: 1) Reducing transport and time costs by bringing services closer to women; 2) promoting the integration of health services (e.g., integrate tuberculosis and primary health services; using antenatal clinics for tuberculosis case-finding); 3) integrating and supporting ‘traditional’ practitioners who provide health care services to women; and 4) increasing supply of female health care providers in the formal system.
  
Other research studies are needed: 1) National tuberculosis control programs should routinely report case-finding and case-holding with analysis by age and sex. 2) Basic epidemiological research to increase knowledge about gender differentials in infection rates, progression to disease, treatment and treatment outcomes.  3) Operational research, with a gender perspective, to develop more effective tuberculosis control programs. 4) Efforts to identify gender-related barriers to tuberculosis diagnosis and treatment should be integrated into overall efforts to improve program effectiveness and identify sources of inequity at the country or regional level to address national or culture-specific barriers to program effectiveness.  5) Basic research to describe the differential impact of tuberculosis on women, men, & their families.


Q1_Title:
Tuberculosis control and directly observed therapy from the public health/human rights perspective

Q2_Key:
public health, human rights, DOT, TB, TB control

Q3b_Both:
The article discusses both internal and external influences on health behavior citing the effects of knowledge, culture and stigma, and the effects of DOT and sociodemographic factors on the rights of the public and the individual.

Q6_ReQue:
In this paper the current international strategy for TB control will be analyzed using the health and human rights framework.  The aim is to introduce different approaches to the current DOTS strategy in order to find more effective and appropriate ways to treat patients with TB.

Q7_TheoBas:
A human rights framework was used to look at disease control.

Q14_Desc:
Directly observed therapy short course (DOTS) is the current international strategy for controlling TB.  Decisions have been taken internationally about the increasing TB epidemic-what to do and why to do it.  But do we know how the DOTS strategy can be implemented most appropriately and what changes need to be made to ensure that it is effective.  This paper uses the Public Health/Human Rights framework to discuss TB control from a human right rather than a biomedical perspective.

Q15_Outc:
Available information indicates that there are problematic disjunctions between TB patients and providers and between the population and the policy makers.  This analysis of TB control from the health and human rights perspective has highlighted the importance of a wider concept of health and of the need to understand TB within the context of people’s everyday lives.  A ‘healthy’ interaction between patients and providers can only be achieved when health care structures are themselves functioning efficiently and effectively.  Development of TB policy and organizing TB control structures must be aware of the process of developing appropriated and ‘healthy’ programs.

Q17_Conc:
This paper argues that key TB dimensions of social, economic and physical access to TB services need to be assessed and accounted for in program design.  This will require that TB control adopt a wider interdisciplinary and multisectoral perspective to complement the current biomedical orientations.

Q18_Recc:
The change in perspective, from patient to programmer, will require more qualitative research and the development of broader outcome indicators than are currently used in TB control programs.


Q1_Title:
Health Culture and the Clinical Encounter: Vietnamese Refugees' Responses to Preventive Drug Treatment of Inactive Tuberculosis

Q2_Key:
Vietnamese refugees, TB, compliance issues, health culture, clinical encounter

Q3b_Both:
The article discussed the clinic setting and patient’s broader sociocultural context (external) within which his/her illness is explored and how it affects interpretations of the origins and meanings of disease (internal).

Q6_ReQue:
This article discussed health culture elements that influence compliance and non-compliance by Vietnamese-American clients with courses of INH preventive therapy for inactive TB.

Q7_TheoBas:
The article emphasized the importance of understanding the health culture or sociocultural context in which the patient is immersed and how it affects his/her interpretations of the origins and meanings of disease.

Q8_SampCom:
36 = 24 individual interviews + 12 f.g. participants

Q12_Oth:
Participant observation in clinics and surrounding community

Q14_Desc:
The article looks at health culture elements that influence compliance and noncompliance of Vietnamese-American clients on isoniazid (INH) preventive therapy for inactive TB.  The research is based on fieldwork undertaken in Orange County, CA, involving: 1) participant-observations in the main county public health clinic, the Refugee Preventive Health Services clinic, and the surrounding community, and 2) ethnographic interviews with clinic clients and staff, community members, and a client focus group.

Q15_Outc:
It appeared that nonclinical, health culture factors were the important forces in determining compliance or non-compliance.  These factors included family members’ and peers’ experiences with INH, general interpretations of the meanings of side effects and of this asymptomatic condition, and the clients’ own understandings of INH and their inactive TB.  Community perceptions of INH were that it is too hot for Asians.

Q17_Conc:
Vietnamese clients on INH as a prophylactic for TB reported many of the known side effects.  However, compliant and noncompliant clients interpreted them as indicators that the medication was too hot for them, causing an imbalance in their bodily homeostatic system and thereby making them ill.  Community interviews supported this interpretation of INH.  The relationship of a client’s health culture to his or her presentation of symptoms and etiology is an important factor to consider when examining the context within which understanding of health and illness are shaped and in analyzing forces that shape the medical message clinicians attempt to impart.  In contrast, the hermeneutic process of the clinical encounter stands outside of or only peripherally intersects, the larger health culture or sociocultural context of the client.  The solution to understanding and shaping cultural understandings into more medical ones involves more than the faces, voices, and cultural heritage of the health care workers.

Q18_Recc:
The reasons why types of side effects were much more varied for noncompliant clients than compliant clients are unknown and warrant further research.  The task of locating and educating potentially supportive family and friends might be done by nonclinics such as community-based organizations or the news media.  More accurate and far-ranging information could be disseminated to the Vietnamese community at large and not simply limited to the clinic’s client population.  A community study to clarify the effect to historical, experiential variables (e.g., experiences in Vietnam with Communist gov’t or US gov’t / military) on compliance with an INH regimen would be important. The mistrust and misinformation about positive PPD tests, the need for INH as a prophylaxis, and some government agencies, point to a need for a community-wide, long term, multidisciplinary health education campaign.  An effective arrangement for funding agencies to pursue would be a partnership between the health departments and the community agencies to develop materials and an outreach strategy. An investigation is needed of the health culture of Vietnamese Americans that is community based rather than clinic based to discern more accurately the factors in compliance and noncompliance.  Further research focused directly on the clinical encounter is needed to understand the exact hermeneutic process involving Vietnamese American clients and health providers, particularly when the latter are also Vietnamese American.


Q1_Title:
The public economics of tuberculosis control

Q6_ReQue:
How effective is the allocation of TB control resources? In what ways do private markets fail to allocate TB control resources efficiently?

Q14_Desc:
This article identifies specific sources of the failure of private markets to allocate TB control resources efficiently. The article reviews economic analyses and priority setting, market failures in the detection and treatment of TB, and the concept of equity.

Q18_Recc:
Government interventions should aim to increase, add to, or substitute for private supply, depending on the type of market failure and the institutional capacity of the public sector. Countries with existing public health infrastructure should consider expanding TB control services, while those with ineffective systems should consider fostering regulated private provision of services.  Society appears willing to pay for improved TB outcomes, but deployment of resources is not accomplished easily or cheaply. Alternative measures should be considered


Q2_Key:
alcohol, TB, compliance, indigent alcoholic, treatment, screening

Q3b_Both:
The article is a review of research on TB and alcoholism.  The article addresses internal factors such as patterns of alcoholics’ adherence to TB treatment, as well as external influences such as homelessness, guidelines for treating and screening alcoholics with TB

Q4_Other:
Review article --cites 48 articles though not identified as a literature review.

Q6_ReQue:
This article describes the effects of alcohol on the development of tuberculosis and focuses specifically on the association between the indigent alcoholic and tuberculosis.

Q14_Desc:
This review article discussed research on alcoholism and tuberculosis and focused on indigent alcoholics (based on 48 article references).  The main topics were epidemiology of alcoholism and tuberculosis, the effects of alcohol on tuberculosis, treatment of alcoholics with tuberculosis, outcome in alcoholic tuberculosis patients, and tuberculosis screening.

Q15_Outc:
Homeless, impoverished alcoholics with TB have a poorer prognosis than others with TB.  The major reason is not a worse response to therapy or medication side effects, but the relative lack of cooperation with therapy.  As outpatients, indigent alcoholics are less adherent in taking prescribed medications and keeping scheduled appointments.  Impoverished alcoholics are more likely to relapse with TB and to resume contagiousness to others.  When they do relapse with TB, their erratic  medication use is more likely to lead to infection with bacteria that are resistant to standard TB medications.   Other factors affecting outcome in homeless, indigent alcoholic TB patients were:  more extensive disease when initially seen in hospital or clinic, malnutrition, associated medical problems (including liver disease), noncompliance with hospital routines, noncompliance with taking prescribed medications, failure to keep medical appointments, disorganized housing situations, infection with drug-resistant strains of Mycobacterium tuberculosis, interactions with medications commonly used by alcoholics. (Many results of studies on TB and alcohol were also discussed.)

Q16_Limt:
Results of studies are conflicting as to the extent to which these abnormalities are related to alcohol consumption itself and the extent to which they are related to the malnutrition and liver damage frequently associated with alcoholism.

Q17_Conc:
Treatment of homeless indigent alcoholic patients with TB is fraught with difficulty.  The emphasis should be on detecting active disease, since this is the greater risk to the individual and the community, especially given difficulties with administering isoniazid prophylaxis for inactive disease and failure to return for skin test reading.  Although the rise in TB in New York area has been attributed largely to the HIV epidemic among IDU, data emphasize the continued role of the impoverished alcoholic in the spread of TB.

Q18_Recc:
In a population with poor follow-up such as indigent alcoholics, the chest x-ray would be the preferable screening method.  The best locations to screen the indigent alcoholic population for TB are the sites of their social service providers, such as welfare programs and homeless shelters.   Comprehensive therapy for the patient’s alcoholism should be offered at the same time as the antituberculosis treatment. If the current increase in TB is to be contained and reversed, adequate resources must be directed to the populations most central to its spread – the indigent alcoholic and the HIV-infected individual.


Q1_Title:
Encompassing treatment with prevention: the path for a lasting control of tuberculosis

Q2_Key:
causality, TB, TB control, health policy, DOTS

Q3b_Both:
Discusses a broad model of causality linking biology, behavior and socio-economic factors.

Q6_ReQue:
This paper argues that a lasting control of TB requires a strategy based on a broader model of causality, which takes into account biological, behavioral and socio-economic factors.

Q14_Desc:
In the paper the author argues that relying exclusively on the current bio-medical model is an inadequate approach to the lasting control of TB.  Therefore, a more complex model integrating the contributing factors in the creation of the TB epidemic is needed.  TB control programs in accordance with this new model would be more efficacious and would achieve lasting effects by combining treatment and preventive actions.  The fundamental problems of the current TB control program and the current epidemiologic model of causality in TB are discussed.

Q15_Outc:
The author proposes three different levels of causality – biological, health behavioral and socio-economic – to explain TB.  This integrated view of causality in TB helps to point out the control measures that need to be taken at different levels of organization, and thus suggests a more comprehensive agenda for research and for action to control the disease.  The different levels of causality are linked to the three stages of the natural history of TB, infection risk, breakdown risk, and death risk, in accordance with the biological perspective.   If those currently involved in TB control really care about people with TB, they must face three challenges simultaneously:  firstly, to keep developing effective means of diagnosis and treatment; secondly, to seek alliances and partnerships with individuals and institutions working at the health-behavioral level of causality; and thirdly, to construct an alternate model of socio-economic development – a model based on less utilitarian principles and that really cares about the poorest.

Q17_Conc:
An integrated approach to TB control, taking into account the biological, health behavioral and socio-economic level of causality, combining prevention and treatment, could produce more effective interventions for the long-lasting control of disease.  Addressing this so-called fundamental causes of disease – unequal distribution of knowledge, money, power, prestige, and social connections – not only would enhance the accomplishments of the goals of the bio-medical model of control, but would also reduce the impact of social disruption on the incidence of TB, contributing to a lasting control of the disease.


Q1_Title:
Pulmonary tuberculosis and health-seeking behaviour: how to get a delayed diagnosis in Cali, Colombia

Q3b_Both:
Both internal and external influences are discussed.  Knowledge of the patient and structured influences of health care facilities.

Q6_ReQue:
The qualitative research looked at the paths followed and the barriers experienced by patients of health care services in Cali, Colombia, while seeking help for pulmonary TB symptoms.

Q8_SampCom:
24 one on one interviews with Tb positive patients; 14 with TB physicians; 16+ with TB nurse assistants; Group discussion: 16 groups with anywhere from 6 - 12 patients each.  Range is 150 to 246 total participants.

Q14_Desc:
This research aims to build up a picture of the pathways that pulmonary TB patients follow and the barriers that they face at the health care services when they seek help from the start of coughing (the epidemic mechanism of TB transmission and the earliest symptom in most cases) until they are diagnosed.  Several qualitative data collection strategies were used: individual structured and individual unstructured interviews, observation, and group interviews with patients.

Q15_Outc:
Results show that the cultural-based explanation patients give to the symptoms, the stigma attached to the disease, and the poor quality of health care services (communication skills, organizational skills, attitudes, and knowledge of the TB control strategy of health care workers) are strong barriers to early diagnosis.

Q16_Limt:
Although the qualitative nature of this research does not make it possible to attribute causal links between these factors and delayed diagnosis, the data suggests that they are related.

Q17_Conc:
Most TB patients actively seeking help are diagnosed later rather than sooner by the health care system, and in the meantime continue to transmit the bacillus.  Correction of these factors through health education of community, improved quality in the health care services, and continued education and supervision of health care workers could help to attenuate the negative impact of delayed diagnosis on the infection risk, the household economy and the probable negative impact on adherence to treatment.


Q1_Title:
Tuberculosis control in less developed countries: can culture explain the whole picture?

Q2_Key:
TB, adherence, stigma, cultural practices, health seeking behavior, organizational behavior

Q3b_Both:
The article discusses both internal and external influences on health behavior citing the effects of knowledge, culture and stigma, and the effects of the organizational behavior of the health care institution.

Q6_ReQue:
A review of research findings published in the literature concerning healthcare practices, adherence to treatment and organizational behaviors of healthcare workers, and the way in which they are affected by cultural and structural factors is presented and discussed.

Q14_Desc:
Although the patient’s beliefs and values in TB control programs should be taken into account, the influence of culture and their behavior is often overstressed. The author will review and assess critically the extent of this influence in the context of the social and economic constraints faced by patients and health care workers (HCW) in the less developed countries.  Relevant reports in the literature published during the 20 years were searched in MEDLINE/EMBASE databases.

Q15_Outc:
Patients’ and HCWs’ culturally determined perceptions of TB and its control has an important, but limited, power to explain their behavior.  In the context of extreme poverty, where most TB patients and HCWs live and work, economic barriers to poorly managed and funded healthcare services could be better predictors of delayed diagnosis, non-adherence to treatment, and inefficiency in healthcare than cultural factors.  Healthcare education which addresses beliefs must be combined with structural interventions, in order to deal with those cultural factors affecting the outcomes of TB control programs.

Q17_Conc:
These findings suggest that structural rather than cultural factors may be the main explanation for the questionable behavior of healthcare workers and patients suffering from TB in less developed countries.


Q1_Title:
Tuberculosis and Stigma: Predictors of Prejudice Against People with Tuberculosis

Q6_ReQue:
The main hypothesis to be tested is that people’s beliefs about mechanisms of TB transmission are the main predictor of the prejudice against PWT.  This article aims to identify the correlates of the instrumental function of the prejudice against people with tuberculosis (PWT) in Cali.

Q7_TheoBas:
The article is based on a psychological perspective, neofunctionalist approach.

Q10_AduOth:
people at risk for TB ages 15 and over in Cali, Colombia

Q10_ACIOth:
people at risk for TB ages 15 and over in Cali, Colombia

Q14_Desc:
A survey exploring the correlates of prejudice against people with TB, as an attitudinal component of this stigma, was carried out in Cali, Colombia through household interviews addressing: sources of TB information, lay notions of causality of the disease, beliefs about the mechanisms of transmission, and feelings and prejudice against people with TB.

Q15_Outc:
All the interviewees reported having heard of TB or having some idea about what TB is, but only 86% thought it was curable.   Sources of information mentioned by the respondents were mass media (i.e., TV, radio and newspapers) (99%), health care and educational institutions (27%), friends and relatives (28%), and direct contact with PWT (14.5%). Regression results show that prejudice against PWT can be predicted from the age, level of fear of PWT, and the beliefs about its transmission held by respondents.

Q16_Limt:
The scale for prejudice towards people with TB was not considered because of its low internal consistency.  Survey sample groups were overrepresented (due to stratification): age groups 45 – 54 and 55 – 64, and low socio-economic groups.  Interaction with HIV & TB not explored because of the relatively low prevalence of AIDS among TB pts in Cali at the time of the study.

Q17_Conc:
This study shows that having scientifically unfounded beliefs about TB transmission and being fearful of people with TB (PWT) are significant predictors of prejudice.  The predominant feelings towards PWT were solidarity, fear and pity rather than anger, loathing or blame.  Multiple regression analysis showed that being older was also a significant predictors of prejudice towards PWT, which can be due to their higher chances than young people of having had direct contact with PWT, and longer exposure to the lay beliefs about TB transmission.

Q18_Recc:
Health education and, arguably, more successful control programs could help to reduce the social isolation suffered by people with tuberculosis.  Making resources for early diagnosis and treatment available and affordable would demonstrate that TB is controllable.  People having this new experience of the disease, combined with health education replacing unfounded beliefs with scientifically based information, could eventually reduce the burden of the stigma and help to improve the quality of life of PWT.


Q1_Title:
Impact of intensified supervisory activities on tuberculosis treatment

Q1_Author:
Jin, B., Kim, S., Mori, T., & Shimao, T.

Q2_Key:
TB, patient, worker, treatment adherence

Q6_ReQue:
This study was conducted to determine the importance of the motivation of the TB personnel in improving treatment results and was designed to incorporate observations of the population’s knowledge, attitude and behavior, and observations of the case-finding process.

Q8_SampCom:
1,300 newly detected tuberculosis patients from 7 health centers

Q10_AduIntl:
Persons with TB in Korea from under 29 years old – 60+ years old

Q14_Desc:
A semi-randomized interventional study design was conducted in order to determine the importance of the motivation of the TB personnel in improving the results of a treatment program.  A total 1,300 newly detected TB patients from 7 health centers were divided into study (n=651) and control (n=649) groups using the health subcenter areas as sampling units.  In the study group, worker motivation was intensified through special regular sessions and closer supervision, while in the control group the usual procedures were followed.

Q15_Outc:
Treatment performance was remarkably improved in the study areas:  treatment completion rate was 78.8% in the study group, compared with 65.2% in the control group. Bacteriologic conversions among those having completed the treatment were 91.9% and 62.2% respectively, and overall efficacy was 75.2% and 45.8%, respectively.  In addition to improved treatment, the follow-up case examinations also showed markedly increased performance.

Q16_Limt:
This study was done in facilities using conventional regimens, which have since been replaced with short-course regimens.

Q17_Conc:
Although this study was done in facilities using conventional regimens which have been replaced with short-course regimens more recently, the study results still clearly indicate the importance of motivating personnel in the field to attain better case management.


Q1_Title:
Trust and Transparency in Human Encounters in Tuberculosis Control: Lessons Learned from Vietnam

Q2_Key:
gender, Vietnam, TB, transparency, trust, health behavior

Q3b_Both:
Stigma and TB control programs (external) and health behaviors (internal influences) were discussed.

Q6_ReQue:
To discover and elucidate understanding of mechanisms important for the TB sickness trajectory, with specific reference to gender differences.

Q7_TheoBas:
Grounded theory method; “gender” is used to imply that men and women have different conditions, experiences, and strategies because of biological, social, cultural and political circumstances.  A model of sickness trajectory was provided.

Q8_SampCom:
40 = 16 health care providers + 24 TB patients

Q12_Oth:
Health care setting:  commune health stations

Q14_Desc:
The purpose of this study was to elucidate understanding of mechanisms of the tuberculosis sickness trajectory in Vietnam. In-depth interviews with 24 TB patients and 16 health care providers involved in TB care were concurrently conducted, coded, and analyzed according to the grounded theory method.

Q15_Outc:
A need for quality interaction based on transparency and trust among patient, family, society, and provider was observed. Providers lacked awareness of differences between male and female patients with regard to social situation and support. In particular, female patients needed social support, as they received less support from their families than men did. A need for active intervention to decrease social isolation and increase social support was more pronounced in families with a female TB patient.

Q17_Conc:
The results of this study emphasize the importance of identifying ways of reducing the economic burden of the individual patient and introducing more flexibility into the interpretation of treatment policies. Special attention should be paid to the social and economic difficulties of female patients who are heads of household.  The various encounters that took place between patient, family, society, and health care system appeared crucial to achieving good treatment results, that is, optimal case finding and case holding.  Furthermore, the quality of the interaction between involved actors appeared to be strongly influenced by the degree of existing transparency and trust that had been established between the parties.

Q18_Recc:
One way of achieving quality interactions is to draw more fully on the potential that lies in former TB patients, the brokers.  Effectiveness evaluations of TB programs should include both program and individual patient costs.  Patient costs are crucial to the treatment of poor patients, in particular poor women, who cannot expect the same support from their families as men receive.


Q1_Title:
Staff and patient attitudes to tuberculosis and compliance with treatment: An exploratory study in a district in Vietnam

Q1_Author:
Johansson, E., Diwan, V., Huong, N., & Ahlberg, B.

Q2_Key:
attitudes; TB; compliance; treatment; exploratory study; Vietnam

Q6_ReQue:
To describe tuberculosis services, attitudes of staff, and attitudes of patients considered as defaulters to TB treatment.

Q8_SampCom:
8 staff members; 10 non-compliant patients

Q14_Desc:
The purpose of the study was to describe the TB services, the attitudes and opinions of staff involved in TB care and those of TB patients considered as defaulters from treatment in a district, as well as the reasons for non-compliance with treatment.  Focus group discussions were conducted with staff members (i.e., medical doctors, nurses, and aide nurses) at the Department of Infectious Disease in a district hospital.  Individual interviews were conducted with non-compliant patients to obtain socio-economic and demographic information and reasons for non-compliance and interruption of treatment.

Q15_Outc:
TB is considered a ‘dirty’ disease, which mainly affects poor people.  There is a tendency to avoid telling others about it.  Obvious symptoms are explained as ‘being overworked’.  A patient with TB feels ‘less respected’ by others.  The social stigmatization leads to delays in seeking medical care, often only after self-medication: anti-tuberculosis drugs can be bought without prescription at local pharmacies.  The patient’s economic situation is also an important determinant of compliance and non-compliance.

Q16_Limt:
The individuals included in the focus groups belonged to different categories of staff, which may have caused some members of different status to not express their opinions as freely.  Only non-compliant patients were included in the study.  A comparison group of compliant patients could have contributed to a better understanding of the problem of non-compliance.

Q17_Conc:
The discrepancy between national recommendations and the reality of TB control in this district could be explained by non-observance of program guidelines by local staff, insufficient training of staff, ineffective supervision and monitoring from the provincial level, and lack of collaboration between provincial district and commune levels.

Q18_Recc:
TB services vary between provinces and districts.  There is a great need to understand the problem of compliance and non-compliance with TB treatment in different parts of Vietnam.


Q1_Title:
Gender and tuberculosis control: Perspectives on health seeking behavior among men and women in Vietnam

Q1_Author:
Johansson, E., Long, N., Diwan, V., & Winkvist, A.

Q2_Key:
TB, gender, health-seeking behavior, Vietnam, stigma, focus group discussion

Q6_ReQue:
How does context (gender roles, socioeconomic status, and education) influence health-seeking behavior?  How is stigma expressed?  How do stigma and delay in health-seeking relate to each other?  How do staff attitudes and quality of health facilities influence health-seeking behavior?

Q7_TheoBas:
Grounded Theory Technique for qualitative data analysis (naturalistic paradigm); Conceptual Framework (Figure 1)

Q8_SampCom:
8-10 participants per group x 4 focus groups in 4 districts = 128-160 total participants

Q14_Desc:
The aim of this study was to explore and describe perceptions of factors influencing health-seeking behaviors in Vietnam with reference to gender differentials in delay in health-seeking.  Focus group discussions were conducted with men and women (people with and without TB) in northern & southern regions, rural & urban areas.

Q15_Outc:
Three main factors contributing to health-seeking delays were identified:  1) stigmatizing effects of TB were mediated through denial and concealment especially among women; 2) fear of high individual expenses for diagnosis & treatment leading to avoidance of public health facilities; 3)  health facilities lack materials resources & human competence.  Additionally, health seeking-behavior is strongly influenced by family structure & gender roles.

Q16_Limt:
1) Focus groups may paint a picture of what’s socially acceptable instead of what’s really occurring or believed to be occurring.  2) Focus groups can be limited when explaining complex beliefs of individuals. 3) Hierarchy between participants according to age in focus group (participants were ages 15-60).

Q17_Conc:
Factors, such as SES, family structure, gender roles, knowledge and image of TB, and education strongly influenced attitudes and health-seeking behaviors.  Stigma seemed to be a summary effect of contextual factors mediated via denial and concealment of disease; more common among women than men.  All factors, whether individually-related factors or system-related factors, affected delays in health-seeking.

Q18_Recc:
Interventions, such as those focusing on health education, reduction of total costs of treatment for individual TB patients, decentralization of TB services and improvement of salaries and working conditions for staff, are needed.


Q1_Title:
Social and operational determinants of patient behavior in lung tuberculosis

Q1_Author:
Juvekar, S., Morankar, S., Dalal, D., Rangan, S., Khanvilkar, S., Vadair, A., Uplekar, M., & Deshpande, A.

Q2_Key:
TB, social determinants, operational determinants

Q6_ReQue:
The paper attempts to understand not only the social and cultural reasons but also operational determinants for the non-conforming patient behavior during anti-TB treatment

Q14_Desc:
A total of 299 patients, 103 rural and 196 urban, were interviewed with the help of a pre-tested, semi-structured, interview schedule.  Information was collected under the following major headings: socio-economic status, knowledge and acceptance of diagnosis, perceptions about attitude towards TB, help seeking patterns for diagnosis and treatment of TB, expenses incurred on treatment and impressions regarding the experiences with the health provider.  This was done to understand social and operational determinants that influence treatment behavior in TB.

Q15_Outc:
This study shows that despite weak, if not missing, health educational inputs, patients’ understanding of TB is satisfactory.  Their preference of private doctors over public health services for TB, their frequent change of health providers for diagnosis as well as treatment, their poor treatment adherence despite knowledge of its ill-effects and their related actions perceived clearly as deleterious to their own good are influenced more by social, economic, and operational factors than by their self-destructive attitude and behavior.

Q17_Conc:
The study concludes that it is the availability, affordability and acceptability of health facilities for TB, factors related to primarily to the provider behavior, that deserve greater and priority attention.  Attempts at rectifying provider behavior are likely to be more productive than those at disciplining patients.


Q1_Title:
Isolation and Stigma: The Experience of Patients with Active Tuberculosis

Q6_ReQue:
What is the experience of patients with active TB?

Q14_Desc:
This article describes a qualitative study of stigma associated with TB. The author conducted semi-structured interviews with 28 individuals attending public health TB clinics. The framework for the interviews was based on Kleinman’s explanatory model, which was developed to allow health care providers to distinguish between “disease” and “illness.” Interviews were taped and transcribed, and analysis was conducted by hand (as opposed to by a qualitative data analysis computer program).

Q15_Outc:
Themes that emerged from the data addressed the following: disease etiology, a sense of being a vector, stigma, self-isolation, avoidance by others, and secrecy.

Q16_Limt:
The study population was very specific, since the interviews were conducted with low income African Americans attending public health clinics.  The author states that the study population cannot be assumed to be representative of African Americans.

Q17_Conc:
The attitudes and experiences described in the study present information about patients with active TB. This information can be useful to community health nurses who provide their care. The findings highlight the inadequacy of a disease specific focus without simultaneously understanding the family and community context. Because incomplete TB treatment has serious community implications, nurse must develop methods that can counter the disease stigma.


Q1_Title:
Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment

Q1_Author:
Khan, A., Walley, J., Newell, J., & Imdad, N.

Q2_Key:
TB; developing countries; DOTS; Pakistan; treatment

Q3b_Both:
This article addresses issues that range from internal influences, such as patients’ knowledge about TB to overarching issues, such as access to health services.

Q6_ReQue:
This study was performed to provide information to assist the researchers to design potential TB treatment delivery strategies (e.g., DOT).  Strategies based on findings from the study are currently being assessed using a randomized controlled trial.

Q14_Desc:
The study was designed to help the researchers understand the extent to which factors related to individuals, the care provision process, and the cultural context influence the behavior of TB patients in Pakistan.  The researchers conducted interviews with 36 new cases (i.e., patients who had never received treatment for TB before the treatment they were currently undergoing).

Q15_Outc:
Results indicate that the majority of patients were very poor, but chose to attend private practitioners.  Patients’ knowledge about their disease was limited, and doctors gave incorrect or very limited health education.  Most patients reported dissatisfaction with treatment, and almost all patients (particularly women who have limited freedom to travel in Pakistan) reported problems (e.g., time and money) with access to treatment.  Deficiencies in treatment provision seemed to be a potential cause of patient non-compliance rather than patients’ unwillingness to comply.  The perception of TB being an incurable disease inadvertently led patients to not disclose that they were undergoing or had undergone treatment for TB.

Q16_Limt:
The sample is not representative of TB patients in general because of the difficulty in tracing registered patients.  Selection bias could have occurred in that patients who were unwilling to co-operate are different from those who did participate in the study.  Recall bias also could have occurred because some information was collected several months after the occurrences on which it was based.

Q17_Conc:
Many of the problems that patients face in trying to obtain good TB treatment are not due to factors related to patients, but are caused by poor service provision.  Factors related to access to services (e.g., cost to patients, both in money and time; distance of services from patients’ homes; and the necessity of accompanying ‘chaperones’ for women patients) must be taken into account while designing DOTS interventions.

Q18_Recc:
Pakistani doctors need training on the importance of health education to encourage treatment completion.  To have successful TB programs, it is essential to provide good quality TB care plus health education to improve the population’s understanding that TB can be cured.  Support needs to be given not only to the patient but the family as well.


Q1_Title:
Urging Health System Research: Identifying Gaps and Fortifying Tuberculosis Control in Pakistan

Q1_Author:
Khan, I., Yassin K, Hurrelmann, K., & Laaser, U.

Q2_Key:
tuberculosis, Pakistan, health care system

Q6_ReQue:
The study  objective was to assess the significance of health systems research in reducing the burden of TB and improving the performance of the National TB control program in Pakistan. A related goal was to assess the level of commitment to research and its impact on TB control in Pakistan.

Q14_Desc:
This article describes a qualitative and quantitative content analysis of research papers on TB in Pakistan that were published between 1960 and 2002, from both national and international perspectives.

Q15_Outc:
Analysis was conducted on 268 research papers on TB in Pakistan. The majority of articles addressed the epidemiology of TB in Pakistan, while others addressed issues such as pediatric TB, TB among Pakistani immigrants, adherence with TB treatment, TB among women, and drug resistance. The analysis showed that research knowledge has yet to be translated in to TB policy and interventions in Pakistan. Findings also indicated that there is a lack of insight on the part of the health care system, in terms of community dynamics and on TB intervention. These two issues have led to failure of achieving the desired targets in the country’s TB program on TB control.

Q17_Conc:
The health system in Pakistan needs to improve TB control interventions by conducting extensive research on the various potential weaknesses in the field. The TB control program is fragmented and case finding in Pakistan is poor. Community and behavioral dynamics that impact TB, and the issue of health care seeking among vulnerable groups, has not been explored.

Q18_Recc:
Health system research should be an integral part of the national TB control program in Pakistan and other endemic countries. Research is needed to  provide a broad-based scientific insight into the country’s vital issues.


Q1_Title:
Study on the knowledge of tuberculosis and attitudes towards the disease

Q1_Author:
Kim, S., Jin, B., Shimao, J., & Mori, T.

Q1_Journal:
Bulletin of the International Union Against Tuberculosis and Lung Disease

Q6_ReQue:
The research sought to address case management problems that are challenging the TB program in Korea. The authors state they desired to study the socio-medical background of patients, family members and neighbors, and also to observe the relationship between the motivational activities performed by health providers, and how these might improve case management.

Q14_Desc:
This article describes research conducted in Korea to address implementation problems being experienced by the country’s TB control program. Using the health center or sub-center as the sampling unit, the eligible population was adults who lived in a neighborhood no further than 5 houses away from newly found TB cases and their family members. Health center staff conducted interviews with 739 family members and 914 neighbors. Questions addressed knowledge about TB, reaction towards the disease, sources of TB information, and where to go for relief of chronic respiratory symptoms.

Q15_Outc:
Educational background was the most important determinant of level of TB knowledge. In terms of reaction towards the disease, one third of respondents indicated they would conceal a TB diagnosis, 60% were reluctant to keep company with someone that was found to have TB. No single source of TB information was identified as most influential. Rural dwellers cited health centers first and hospital second for where they would go if they had TB symptoms. Urban dwellers chose clinics or hospitals first and health centers after that. In urban areas, chemists (pharmacies?) tended to also play a major role.

Q17_Conc:
Study participants understanding or knowledge of TB was found to be superficial and likely to be influenced by both traditional ways of thinking as well as the modern but often wrong opinions. 
In terms of reaction towards the disease, urban dwellers seemed to be more conservative than rural dwellers.

Q18_Recc:
Information and public relations efforts should be planned comprehensively as no single source of TB information was singled out.


Q1_Title:
New Linkages for Tuberculosis Prevention and Control in New York City: Innovative Use of Non-Traditional Providers to Enhance Completion of Therapy

Q2_Key:
New York City, TB, prevention, control, DOT

Q3b_Both:
Patient compliance with TB treatment regimens (internal) and programmatic changes to TB program (external) were described in the article.

Q6_ReQue:
To facilitate completion of therapy in NYC, the State Health Department created a program to offer Medicaid reimbursement beginning in 1992 to support individuals to observe clients with active disease complete their treatment regimens, and was the first state to do so.

Q7_TheoBas:
Principles of community empowerment and groundwork for implementing this expanded DOT strategy were discussed.

Q14_Desc:
To maximize completion of treatment, DOT was made available through local organizations in the community already serving high-risk, hard-to-reach individuals.  Hospitals, outpatient clinics, neighborhood health centers, AIDS Centers, substance abuse treatment programs, shelters, and supported housing programs were ideally suited as sites of opportunity.  Outreach was used to offer DOT anywhere in the community.  As a public health control measure, DOT would prevent clients from becoming infectious again, from developing drug resistance, and from spreading disease to their close contacts and to the community.

Q15_Outc:
Despite limitations and obstacles which threatened the success of the new initiative, availability and use of DOT for persons with active disease in the City expanded dramatically as a result of the coalition of public and private community DOT providers created in 1992. Over 250 individuals were reported to have completed their therapy while enrolled.

Q16_Limt:
Upon completion of treatment, individuals who have been engaged in DOT and have benefited from supportive relationships and access to needed services face being isolated.  This dynamic can act as a disincentive for completion of treatment and it can lead to a return to living conditions and social situations, which led to development of active TB disease.

Q17_Conc:
Involvement of community organizations with the providers offering DOT in NYC has been found to be an effective means to make the health care system more accessible and more user friendly. Community approaches involving new collaborations can optimize efforts of individual organizations and collective efforts, facilitate shared goals, foster creativity, enable flexible and timely responses and strengthen the overall community environment.

Q18_Recc:
Recommendations:  This new disease prevention and health promotion model has direct and indirect applicability to many other complex communicable disease, chronic disease and social issues.  Success thus far with difficult to serve individuals with TB suggests ready adaptability of this model to other major public health problems such as cardiovascular, oncologic and metabolic diseases.  While substantial progress in forging new linkages between public health, the traditional health care delivery system, social service agencies, and CBOs has been achieved, on-going efforts must be sustained to fulfill our joint goals. Linkages between DOT providers and CBOs can build safety nets to aid clients through TB treatment and bridge gaps during and after the transition back into the community upon hospital discharge and upon completion of DOT.


Q1_Title:
Frameworks Matter: Ecosocial and Health and Human Rights Perspectives on Disparities in Women's Health - The Case of Tuberculosis

Q1_Journal:
Journal of the American Medical Women's Association

Q2_Key:
TB, women, gender, disparities, tuberculosis control, ecosocial theory, health and human rights

Q6_ReQue:
This article presents 2 frameworks (ecosocial and health and human rights) that if considered singly and combined, could prove useful to furthering work on understanding and addressing societal patterns of health, disease, and well-being with reference to women, girls and tuberculosis.

Q7_TheoBas:
2 theoretical frameworks are explicitly described: ecosocial theory and health and human rights.

Q14_Desc:
To illuminate how being explicit about theoretical frameworks can engender systematic inquiry useful for understanding and guiding actions to address health, the article identifies similarities and differences in ecosocial and health and human rights approaches as well as issues and gaps in research and action.  The authors draw on ecosocial and health and human rights concepts to develop a series of questions about factors determining the social patternings of, experiences of, and responses to tuberculosis among women.

Q15_Outc:
Ecosocial theory draws attention to social and biologic factors conjointly generating observed distributions of disease.  A health and human rights framework considers the underlying civil, political, economic, social, and cultural determinants of health and the ways in which human rights can be promoted, neglected, or violated in the ways that policies and programs are designed and implemented.   Bringing the 2 frameworks together illustrates that even as questions may be posed differently, there is a significant overlap in approach and concerns.  Both draw attention to determinants of health, accountability for these determinants and monitoring population health.

Q17_Conc:
The questions posed in this article are a first step in investigating what is being done about tuberculosis, overall and in relation to women.  The next steps are to synthesize common queries and extend analysis of these differences to see how this influences the questions we ask, and to apply a modified set of questions to assess current knowledge and practice.  More generally, the approach explored in this article is transferable to other health conditions.  Explicit articulation not only is useful in and of itself, but also helps communicate more clearly across disciplines.  The challenge of articulating and applying frameworks, separately and in relation to each other, additionally underscores the importance of bringing multiple perspectives to bear on public health issues.  The point is to employ explicit perspectives consciously.  Frameworks matter.

Q18_Recc:
The article provides detailed questions about women and tuberculosis prompted by ecosocial theory and health and human rights framework that demand further attention (see article).  Ecosocial theory questions address embodiment, pathways of embodiment, cumulative interplay between exposure, susceptibility, and resistance; accountability and agency.  Health and human rights framework questions address:  impact of neglect or violation of human rights on vulnerability to tuberculosis; and tuberculosis policies, programs, and practices.  Working in common, with different and complementary insights can set the basis for new work for global health.


Q1_Title:
Knowledge of the Transmission of Tuberculosis and Infection Control Measures for Tuberculosis Among Healthcare Workers

Q1_Author:
Lai, K., Fontecchio, S., Kelley, A., & Melvin, Z.

Q2_Key:
Healthcare workers, hospital, knowledge, transmission

Q6_ReQue:
Objective:  To test the knowledge of health care workers regarding the transmission of tuberculosis, and the infection control measures that the CDC recommends.

Q8_SampCom:
275 HCWs (325 HCWs were given the survey)

Q14_Desc:
In August 1993, the Infection Control Department of UMMC ran all-day educational programs on infection control and Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standards.  A questionnaire was distributed at the outset to test participants’ knowledge of the transmission of TB and infection control measures for preventing its transmission among HCWs.  Completed questionnaires were collected at the end of these sessions.  Questions asked included the risk of contracting TB at work, modes of transmission, employee health services available for purified protein derivative (PPD) skin testing and exposure workups, infection control measures for TB, and participants’ recent experiences with TB education and training.

Q15_Outc:
Of 325 HCWs who were given a copy of the questionnaire, 275 completed it, 200 with patient contact (66 doctors, 83 nurses, and 51 others) and 75 without patient contact.  Two hundred thirty-three participants (85%) agreed that HCWs were at risk for TB at work.  Of the 75 HCWs with no patient contact, 49 (65%) felt that masks should be worn, and 40 (53%) would use gowns.  In contrast, 175 (88%) of 200 HCWs having contact with patients thought masks should be worn, and 70 (35%) would use gowns (P=.0001 and .0085, respectively).  Only 87% of HCWs with patients contact felt that respiratory precautions should be instituted for TB patients.  Among HCWs with patient contact, 91% agreed that they were at risk for TB at the workplace.  Fewer than 50% had received TB education in the past 2 years.  Only 88% were aware of the necessity of at least a yearly PPD skin test and the need for a chest X ray for employees with positive PPDs or for persons whose skin tests were newly converted.

Q17_Conc:
The authors’ survey showed that HCWs with and without patient contact differed significantly in the knowledge of the transmission of TB and infection control measures for the prevention of its transmission and, furthermore, HCWs with patient contact had gaps in their understanding of TB transmission and infection control as well.  The fact that 35% of HCWs with patient contact thought that they needed gowns to take care of TB patients showed their lack of understanding of the modes of transmission of TB.

Q18_Recc:
The authors recommend the reeducation of HCWs (students, residents, fellows, physicians, nurses, technologists, administrators, and volunteers) about the clinical presentations of TB, the identification of high-risk groups, the modes of transmission of TB, the infection control measures of the hospital, and the availability of employee health services for counseling HCWs about TB, including annual PPD skin testing.  This will heighten awareness and decrease the delay of diagnosis, facilitate early and efficient isolation, and prevent unnecessary exposures of HCWs to TB.


Q1_Title:
Pediatric emergency physicians and communicable diseases: Can we be trusted to take care of ourselves?

Q1_Author:
Lane, N., Paul, R., Bratcher, D., & Stover, B.

Q2_Key:
TB, immunity, vaccines, Pediatric Emergency Physicians

Q6_ReQue:
To determine if pediatric emergency physicians (PEP) are following CDC recommendations that all health care workers receive routine vaccines and annual TB screens.

Q8_SampCom:
407 surveys sent out => 286 returned => 209 met inclusion criteria and were use for analysis

Q14_Desc:
In March 1994, a 2 page mail survey was sent to all active members of the American Academy of Pediatrics (AAP) Section on Emergency Medicine, with on follow-up mailing in April 1994.  This study was performed on a physician population that has a high risk of exposure to vaccine-preventable diseases and TB to determine their reported immunity status and their institutions’ immunity surveillance policies.

Q15_Outc:
Of 407 surveys, 286 (60%) were returned; 209 met inclusion criteria.  Proof of immunizations was not required of 43% of PEP; 42% were not required to have an annual TB screen.  PEP reported immunity to the following: polio (95%), measles (94%), hepatitis B (91%), rubella (90%), mumps (90%), varicella (90%), and diphtheria-tetanus (86%).   However, only 72% received a TB screen, and 60% received an influenza vaccine within the past year.  Proof of vaccination for employment was required by 57/85 hospitals, 47/79 universities, and 6/32 self-employed/group practices (P < 0.001).  PEP were more likely to have had a recent annual TB screen if required by their employer (104/117) than if left to their own initiative (42/87) (P < 0.001).

Q16_Limt:
Several limitations of this study deserve comment.  First, despite 2 mailings, the response rate was 60%; and 26% were further eliminated, owing to in-training status.  It is unknown how many of the 40% non-responders were also in training and therefore it is unclear how many of employed non-training PEP were eligible for the study.  In addition, only members of the Section on Emergency Medicine of the AAP were surveyed, introducing a potential selection bias.  The potential for ambiguity resulting in incorrect answers was still a possibility.  There were, however, few un-interpretable answers.  Finally, no blood specimens were collected for serologic proof of true immunity status.  Historical information and honesty of respondents was accepted as accurate.

Q17_Conc:
Although PEP are well protected against most vaccine-preventable diseases, many are not receiving annual TB screens not influenza vaccines.  The CDC guidelines are not being routinely followed by PEP.


Q1_Title:
An Intervention to Improve Compliance to Year-Long Isoniazid (INH) Therapy for Tuberculosis

Q1_Journal:
The Journal of Compliance in Health Care

Q2_Key:
TB, Isoniazid, compliance, pill-taking, treatment dropout.

Q6_ReQue:
Research sought to determine the effectiveness of a medication calendar intervention in the reduction of non-compliance with medication treatment.

Q7_TheoBas:
No social or behavioral science theory is explicitly discussed, but research is based on the effectiveness of similar interventions with individuals on medication therapy for hypertension.

Q8_SampCom:
28 (18 in experimental group and 10 in control)

Q13_Comm:
When simple comparisons were made between the two groups, the mean monthly compliance scores were identical, so no difference was found and no statistical tests were performed.

Q14_Desc:
The article discusses the development of medication therapy with Isoniazid for TB and the importance of patient compliance to the success of treatment.  It tests a simple intervention designed to bolster medication compliance via the use of medication calendars.

Clients were randomly assigned to either the experimental (received detailed medication calendars upon diagnosis and initiation of therapy) or control (no calendars, regular treatment).  Follow-up visits were identical between groups, and were used to assess compliance with the regimen on several dimensions including pill-taking, cessation of pill-taking and physician contact when experiencing hepatic side effects, etc.).  From this information, a monthly compliance score was generated for each patient.

Q15_Outc:
There were no significant differences between the groups.  As a matter of fact, the mean of mean monthly compliance scores presented for the two groups was identical (84.3).  Therefore, there was no effect found for the intervention.

Q17_Conc:
There was no effect of the intervention on pill-taking, which was very high.  The authors suggest a ceiling effect as a potential explanation, as both groups performed very well in pill taking.  The only major reduction in compliance scores was among individuals who dropped out of treatment, rather than shortcomings in pill taking among those who remained.

Q18_Recc:
Future interventions should potentially focus on keeping patients in treatment (reducing drop-out) rather than pill-taking with individuals still in treatment.


Q1_Title:
Pulmonary tuberculosis: diagnostic delay in Ghanaian adults

Q2_Key:
TB, diagnostic delay, physician adherence, diagnosis, Africa

Q6_ReQue:
The aim of the study is to determine the factors affecting the delay from onset of symptoms of pulmonary TB until the initiation of treatment.

Q14_Desc:
A retrospective questionnaire survey of 100 adults was conducted by interviewing patients newly diagnosed with smear-positive pulmonary TB at the Komfo Anokye Teaching hospital Chest Clinic in Kumasi, Ghana towards the end of 1995.

Q15_Outc:
The median total delay in diagnosis was 4 months (mean = 7.7), and the total delay exceeded 6 months in 44% of patients.  Total delay was strongly associated with rural residence (P = 0.001).  The medical doctor delay from the first consultation until diagnosis was double the median patient delay in initial presentation (8 weeks versus 4 weeks).  Doctor delay was significantly increased in females, rural patients, and among those needing hospital admissions.  Increased doctor delay was strongly correlated with rates of failure to perform sputum microscopy (r = 0.99), low rates of diagnosis was seen particularly among private practitioners and rural government institutions.

Q17_Conc:
Delays in the diagnosis of pulmonary TB are prolonged in Kumasi, Ghana, with a frequently length doctor delay.  The new National TB program is decentralizing the diagnosis and management of TB, with the introduction of widely available sputum microscopy and rigorous training of health personnel.  This should help to reduce doctor delay and thereby improve TB control.  Serial studies of this nature will help to identify the area of weakness in the TB Control program, and will thus contribute to its strengthening.

Q18_Recc:
This study should be repeated after a few years, it may show whether the National TB program has been effective.


Q1_Title:
Tuberculosis:  A Reflection of Political Institutions and Social Concerns in the United States

Q14_Desc:
This article reflects upon the social and political history of TB over time. Specifically, the review is divided into three time periods: Prechemotherapy Treatment, the Modern Era, and Tuberculosis Today and in the Future. Each section provides an illustration about how the TB sanitarium/governmental movement influenced TB control measures and ultimately affected individuals.

Q17_Conc:
In retrospect it appears the TB movement in the U.S. is a painful reminder of how human institutions may become self-serving to the extent that they inflict suffering on those whom they initially sought to help.


Q1_Title:
Tuberculosis Control Policies in Major Metropolitan Health Departments in the United States

Q2_Key:
health policy, urban health, TB control, prevention, drug therapy

Q6_ReQue:
To assess the standards of practice for TB treatment and prevention in 1992 and to determine what changes in both disease and treatment policies occurred in the previous 14 years.

Q11_USA:
26 locations--for details, see #19 additional comments

Q13_Comm:
Paired t-test with Bonferroni correction for normal distribution, and Wilcoxon’s sign-rank test or chi-square analysis for non-parametric distributions.

Q14_Desc:
Since 1978, we have surveyed the 28 metropolitan health departments initially reporting > 250 cases of tuberculosis/yr to determine the standard of practice in the control of pulmonary tuberculosis and the factors affecting treatment policy. In this survey, results were compared with data obtained in 1978, 1980, 1984, and 1988. As in the previous years, all departments completed the survey.

Q15_Outc:
The predominant treatment regimen was 6 months of chemotherapy (64 +/- 1.33% of patients) involving isoniazid (I), rifampin (R), and pyrazinamide (Z). Estimated duration of treatment, which had decreased from 20.2 +/- 2.1 months in 1980 to 7.58 +/- 1.02 months in 1988, increased to 9.34 +/- 2.32 months in 1992 (p < 0.01). This was attributed to an increase in drug-resistant cases (17 of 25 programs) and to increased incidence of HIV infection during the previous 4 yr. In 1984, HIV infection was estimated to coincide with tuberculosis in 2.54% of all patients, 7.72% in 1988, and 17.42% in 1992. Several other major departures from prior perceived practices were reported. In 1980, 32.1% of all patients were hospitalized initially for tuberculosis treatment, and this number decreased progressively to 17.8% in 1988; in 1992, 34.2 +/- 1.32% of patients with tuberculosis were hospitalized for initial treatment. In 1988, no program reported regular use of alternative therapy to isoniazid for chemoprophylaxis; in 1992, 21 programs used alternative regimens (predominantly R-containing). In 1992, nine programs reported increased funds for treatment of tuberculosis (27.2 +/- 1.97% after inflation), whereas 16 reported a mean decrease of 14% after inflation.

Q16_Limt:
Data are a survey of estimated treatment practices by TB control officers over a 14 year period. These persons were not asked to review records due to a lack in uniform methods among health departments for data requested. Thus, many of the data are solely opinion questions and considered policy data and estimates of practices rather than quantitative data.

Q17_Conc:
TB treatment in major metropolitan health departments in U.S. consists predominantly of short-course chemotherapy utilizing I, R, and Z and that overall mortality is not reported to be greater because of initially drug-resistant organisms. However, HIV-associated disease is now a major etiologic factor in TB and the number of hospitalizations has doubled in 4 years. Despite diminished resources, incidence of hospitalization and duration of treatment have increased for the first time in 12 years. In the absence of an increase in funds for treatment, problems currently identified in TB control by major metropolitan health departments likely will be exacerbated in the immediate future.


Q1_Title:
From Careless Consumptives to Recalcitrant Patients: The Historical Construction of Noncompliance

Q2_Key:
TB, patient compliance, history of medicine, evidence-based medicine, physician-patient relationship, managed care programs, compliance, adherence

Q6_ReQue:
This paper, which reviews how noncompliance has been constructed historically, argues that the problem with noncompliance is more than just one of terminology.  Changing social and cultural factors during the 20th century have influenced the way in which uncooperative patients have been described.

Q14_Desc:
Using 20th century TB control efforts in the US as a case study, this paper first reviews the various terms that physicians have used historically to describe patients who disregard their advice.  Next, it looks more broadly at the concepts of compliance and noncompliance as developed by Sackett and Hayes in the 1970s.  Despite attempts to fashion a nonjudgmental term, noncompliance still retains earlier notions of deviance.  The paper concludes with thought regarding the issues of noncompliance in an era of managed care medicine

Q15_Outc:
Rather than replacing the paternalistic word “compliance” with a more benign term respectful of patient autonomy, the need is to integrate the issue of compliance into a model that accepts both a degree of physician control and patient resistance.  In such a system, replace the question “How can we make a noncompliant patient compliant?” with a different question: “To what extent (and on what ways) should a physician encourage a given patient who is resisting his or her advice?”  A helpful strategy for approaching this latter question might include the use of narrative knowledge, in which the physician examines clinical dilemmas “within the framework of a patient’s culture and biography.”

Q17_Conc:
History suggests that labels such as “noncompliant” are invariably judgmental.  Rather than seeing the provider’s role as trying to get noncompliant patient to comply, we should emphasize the importance of negotiation and accommodation within the provider-patient relationship.


Q1_Title:
New York City's Tuberculosis Control Efforts: The Historical Limitations of the 'War on Consumption'

Q6_ReQue:
This purpose of this article was to address that cities, like NYC, need to design new strategies to control TB because a revival of traditional measures will likely have limited success.

Q14_Desc:
The goal of the article was to give a historical perspective of NYC's TB control efforts.  The difficulties encountered by New York’s anti-TB campaign highlight two questions that have continually confronted public health officials: (1) What criteria should be used to prioritize among various preventative health programs?  (2) Should public health work only target individual disease or also advocate larger social reform?  New York and other cities designing new strategies to control TB must address these questions because a temporary revival of traditional measures alone will likely have only limited success.

Q15_Outc:
TB control in the city has been limited by two problems that hamper many public health programs: (1) anti-TB measures, while appropriately targeting the poor, have been inconsistently funded and poorly coordinated, and (2) efforts have emphasized detection and treatment of individual cases rather than improvement of underlying social conditions.

Q17_Conc:
Two problems that confront public health programs have continued to limit the success of these efforts.  The first problem is how public health agencies should best allocate limited resources.  The second problem is that health campaigns of this century have generally not addressed the underlying social conditions that allow diseases like TB to persist.  Nevertheless, as a result of the structure that public health has assumed, TB control has sought to detect and treat disease in individual persons rather than address larger social ills.  Renewed efforts by New York and other cities must address these limitations.

Q18_Recc:
Future research should center on evaluating various control strategies “on the basis of their clinical and public health importance and their cost-effectiveness.”  Even with adequate funding, anti-TB efforts must address the second historical limitation: the persistence of poverty.


Q1_Title:
Temporarily Detained:  Tuberculosis Alcoholics in Seattle, 1949 through 1960

Q2_Key:
alcohol, homeless, TB, history, complications

Q6_ReQue:
The article is a historical/policy review of the treatment and detainment of TB alcoholics in Seattle, WA 1949-1960.

Q14_Desc:
This article is part of the AJPH’s “Then and Now” series and describes the history and policy behind detainment of TB alcoholics in Seattle from 1949-1960.

Q15_Outc:
Contrary to regulations, the Firland Sanatorium staff used public health criteria to detain TB patients without active disease, and also adopted an informal policy requiring alcoholics to remain hospitalized for 12 months. In 1949, Seattle's Firland Sanatorium established a locked ward. Although initially intended only for active public health threats, the ward was eventually used to maintain order among Firland's alcoholic patients. That is, the staff detained alcoholics--regardless of their infectivity or compliance with medications--for breaking sanatorium rules. In this manner, maintaining institutional order became a legitimate reason for invoking public health powers.

Q17_Conc:
Three main conclusions: (1) Laws and regulations have not prevented the possible misuse of authority by those carrying out public health policies; (2) public health employees should employ coercion based on the likelihood that an individual is at risk for spreading infection, and not based on a category to which an individual belongs; and (3) for patients detained in inpatient facilities, officials must not confuse custodial or management issues with public health goals. Although new detention regulations strive to protect patients' civil liberties, attention must also be paid to the day-to-day implementation of coercive measures. When public health language is used to justify administrative or institutional requirements, disadvantaged patients may be stigmatized.

Q18_Recc:
Repeatedly noncompliant tuberculosis patients (who are often homeless or substance users) are once again being forcibly detained. Health officials intend that confinement be used only when "less restrictive alternatives" have failed. Past programs of detention can inform current efforts.


Q1_Title:
Attitudes and knowledge of newly diagnosed tuberculosis patients regarding the disease and factors affecting treatment compliance

Q6_ReQue:
The aim of this article was an exploration of the knowledge and attitudes of newly diagnosed TB patients regarding the disease and factors affecting treatment compliance.

Q14_Desc:
As part of a patient education program, newly diagnosed TB patients were interviewed so that knowledge and attitudes towards the disease and treatment could be assessed. Compliance with treatment was assessed by a retrospective review of hospital clinical records.

Q15_Outc:
The study revealed limited knowledge and serious misconceptions about TB and its treatment among newly diagnosed patients attending a university teaching hospital. The majority of non-compliant patients defaulted within the first two months of initiation of treatment.

Q17_Conc:
A large proportion of TB patients do not understand the symptoms of the disease and have limited knowledge and many misconceptions about its transmission and treatment.

Q18_Recc:
Patient education needs to target misconceptions about TB.  Counseling for patients and family members about the necessity of treatment completion may play a role in improving compliance.


Q1_Title:
Delay in the diagnosis and treatment of pulmonary tuberculosis in patients attending a university teaching hospital

Q2_Key:
Diagnosis, delay, university hospital, treatment

Q6_ReQue:
Objective:  To investigate patient and doctor delays in the diagnosis and treatment of pulmonary tuberculosis in patients attending a tertiary teaching hospital.

Q13_Comm:
Probability values of less than 0.05 were considered to be statistically significant.

Q14_Desc:
The authors interviewed a total of 97 patients with newly diagnosed pulmonary tuberculosis at the University Hospital in Kuala Lumpur to study the process of case-finding since the onset of TB symptoms.  (The authors derived their sample by interviewing all patients who were diagnosed during a 15-month period from September 1994 to November 1995.)  The authors determined the time intervals between onset, first medical consultation, and the final diagnosis and commencement of anti-tuberculosis treatment.  They evaluated demographic and clinical features for their effect on these intervals.

Q15_Outc:
Thirty-six cases were sputum smear-positive and 61 were smear-negative.  Tuberculosis was eventually confirmed in 32 of the smear-negative cases.  The medians of patient delay, doctor delay, and total delay were 2 weeks, 7 weeks, and 12.5 weeks, respectively.  The majority of the patients consulted private general practitioners, but the diagnosis of tuberculosis was rarely suspected; chest X-ray and sputum examinations were under-utilized.

Sixty-one percent of the symptomatic patients had taken action by seeking medical attention within 2 weeks and 80% within one month of onset of their symptoms.  Only 6.2% out of a total of 161 private general practitioners consulted by all 94 symptomatic patients suspected tuberculosis.  On the other hand, tuberculosis was suspected by 43.8% of 73 hospital-based doctors consulted (P<0.001).

Q16_Limt:
The low number of patients who were given a TB diagnosis by their general practitioners can be attributed to a number of factors:  among them, a low level of awareness of the disease and poor diagnostic skills on the part of the GP.  However, the information on whether the patient was told that TB was suspected depended entirely on the patients’ recall in most cases.  The actual percentage of general practitioners who considered the diagnosis of tuberculosis may have been higher.

Q17_Conc:
It is imperative that doctors be more alert to the possibility of pulmonary tuberculosis in patients with respiratory symptoms so that it can be diagnosed early and treated promptly to reduce patient morbidity, as well as to limit the disease’s spread in the community.  The findings of this study and the remedial measures to shorten both patient and doctor delays may be applicable in many countries with the same socio-economic and cultural backgrounds as Malaysia, as well as those with a similar health care delivery system.

Q18_Recc:
Doctors in private practice who do not have ready access to radiological and sputum examination facilities should rapidly refer patients who are suspected of having tuberculosis to the government chest clinics or teaching hospitals, depending on which ones are more accessible to the patients, for further assessment.  Efforts should be made to improve the diagnostic skills and the awareness of tuberculosis of all doctors, particularly general practitioners, since most patients first seek treatment from them.  Education on the clinical and public health aspects of tuberculosis should be intensified at undergraduate and post-graduate levels in the medical schools.  There should also be continuing medical education on tuberculosis in the form of lectures, conferences, or seminars organized by professional bodies and associations involved in the treatment and prevention of tuberculosis, with contributions of expertise from the national tuberculosis control program.


Q1_Title:
Gender Differences in Beliefs and Attitudes towards Tuberculosis and their Impact on Tuberculosis Control: What do we know?

Q2_Key:
Gender, beliefs, attitudes, Third World, socio-cultural

Q6_ReQue:
Objective:  This paper reviews the existing literature on gender differences in beliefs surrounding TB and attitudes towards the disease.  Findings are analyzed for their relevance to TB control programs and their implication for research priorities in low-income countries.

Q10_AduIntl:
Pakistanis from Sialkot; Bangladeshis from Netrakona; and Kenyans from Uasin-Gishu

Q10_ACIIntl:
Pakistanis from Sialkot; Bangladeshis from Netrakona; Kenyans from Uasin-Gishu

Q11_Intl:
Sialkot, Pakistan; Netrakona, Bangladesh; Uasin-Gishu, Kenya

Q14_Desc:
This article discusses the ways in which socio-cultural factors differ according to gender, and the impact of these differences on Third World tuberculosis control programs.   The author obtained information for this paper from two sources.  The first source was material from an extensive literature review conducted through Medline and Popline.  The second source was her own previous ethnographic and epidemiological studies assessing the underlying cognitive, cultural, and emotional reactions toward TB, carried out in Sialkot, Pakistan; Netrakona, Bangladesh; and Uasin-Gishu, Kenya.  (The aim of these studies was to examine the magnitude and the causes of treatment delay and to assess the risk factors of defaulting.)

Q15_Outc:
The author divided her results into 11 sections:  knowledge and perception of TB, recognition of early signs and symptoms of active TB, etiological beliefs of TB, pregnancy and TB, belief in the curability of TB, intention to comply, emotional reaction towards TB diagnosis, TB and stigma, denial, perception of TB treatment, and perceived barriers to treatment.  In Sialkot, Pakistan, especially, adherence to TB treatment varied significantly according to etiological beliefs and gender (see Table 1, page 94).  

While women and men share many beliefs concerning the cause of TB, some differences were found that apparently affect TB control.  Knowledge of the infectious origin of TB was related to a shorter delay among men but not at all to a better treatment adherence.  Clearly, information plays a minor role in the complexity of treatment adherence.  Qualitative studies show pregnancy to be a reason for treatment defaulting but this has not been confirmed by quantitative findings.

Q16_Limt:
The author was able to find studies on attitudes and beliefs surrounding tuberculosis, though several showed inconclusive and even contradictory findings.  This is not surprising given the wide variety of cultural contexts in which the studies were carried out and the fact that ethnic groups differ in their cultural practices.  The author of this article found some methodological problems in the designs of the studies that she cited, small sample size being one of them.  Another problem was the validity of the instruments used to measure beliefs and feelings.  One example of the problem was the difference in degree of stigmatization as brought forward by the patient and the community.

Q17_Conc:
Considering the constraints that many women face in the Third World, it seems reasonable to expect a longer delay among women and a lower treatment adherence.  The author’s studies show that treatment delay was shorter among women and that they complied slightly better with treatment than did men.  The latter finding tallies with the findings from other parts of the world.  This may be explained by the fact that women have a stronger motivation to comply at the start of treatment.  Another possible explanation is that only the motivated women reach the health services.  This hypothesis cannot be confirmed yet as no information is available on those women who have no access to health services.

Q18_Recc:
Further research is necessary to understand the nature of the burden of TB on men and women.  Methodologies such as the explanatory model interview catalogue (EMIC) may be introduced to obtain more comparable findings.  These interviews include both qualitative and quantitative variables.  Patterns of distress, perceived causes, health-seeking preferences and beliefs are the components of this operational formulation of the illness explanatory model.


Q1_Title:
From their own perspective. A Kenyan community's perception of tuberculosis

Q1_Author:
Liefooghe, R., Baliddawa, J., Kipruto, E., Vermeire, C., & De Munynck, A.

Q2_Key:
TB, knowledge, perceptions, health seeking behavior, patient delay

Q6_ReQue:
This study sought to understand the community’s beliefs and knowledge about the causation, transmission and symptomatology of TB; to determine treatment-seeking behavioral patterns in TB suspects; and to assess attitudes towards the disease and afflicted patients.

Q8_SampCom:
5 Focus group discussions: rural subjects: (G1) 13 men, (G2) 11 women; urban subjects: (G3) 9 men, (G4) 8 women; TB positive subjects: (G5) 8 men

Q14_Desc:
Early passive case finding and treatment compliance are the cornerstones of TB control programs.  As human behavior plays a critical role in both strategies, a better understanding of it is important for the planning and implementation of a successful TB program, especially for the health education component.  Our qualitative study in Uasin Gishu, Kenya, aimed at a better understanding of the community’s beliefs and perceptions of TB, recognition of early symptoms and health seeking behavior.  Five focus groups with a total of 49 people were held; one with hospitalized TB patients, two with rural and two with urban participants.

Q15_Outc:
TB is well known in the community and many vernacular names for the disease exist.  TB is perceived as a contagious, ‘sensitive’ disease difficult to diagnose and treat.  Community members believe that TB should be diagnoses and treated in a hospital or by a medical doctor and not at the peripheric level.  TB treatment is perceived as long, agonizing and cumbersome.  Traditional treatment is considered a valid alternative to modern treatment, believed to be as effective and much shorter.  Initial symptoms such as cough and fever are often overlooked and/or confused with malaria or a common cold.  Symptoms associated with the disease refer to the later stage of TB.  TB is attributed to causes such as smoking, alcohol, hard work, exposure to cold and sharing with TB patients.  Many participants believe TB is hereditary.  Prolonged self-treatment and consultation with the traditional health sector as well as the social stigma attached to the disease increase patient’s delay.  Only after symptoms persist for some time and/or the suspect’s health deteriorates, are modern health services consulted.

Q16_Limt:
Purposive sampling of participants was chosen rather than random sampling because it has the advantage of the willingness to participate actively, resulting in good informativeness of the group discussions.  For operational reasons only a group of male TB patients was included in the FGD.  The data provide no more than a glimpse of the behavioral factors affecting TB control and the finding may only be applied to the factors studied.  While the sample included participants form several ethnic groups of Kenya, it is not necessarily representative of the whole population of Kenya.  Although the FDG method has recently been advocated as a viable stand-alone procedure, triangulation with other studies would increase the validity of the results.

Q17_Conc:
Social conditions necessitate culturally sensitive health education, taking into account local perceptions of TB.

Q18_Recc:
The rate of delayed TB diagnosis and its reasons among symptomatic patients who present to a health facility requires further investigation and remedial measures.  Further research is needed to assess more precisely the actual role of traditional healers in TB treatment.  Several key persons such as teachers, community leaders, neighbors, and local health workers are mentioned as being influential in the health seeking behavior.  Their potential has not been explored thoroughly.


Q1_Title:
Perception and social consequences of tuberculosis: A focus group study of tuberculosis patients in Sialkot, Pakistan

Q1_Author:
Liefooghe, R., Michiels, N., Habib, S., Moran, M., & De Muynck, A.

Q2_Key:
TB, focus group study, defaulting, risk factors, stigmatization, cost, pregnancy, Pakistan

Q3b_Both:
Both types of influences were discussed: beliefs and perceptions about TB and pregnancy (internal), social consequences (external), such as stigma toward TB patients and their families.

Q6_ReQue:
The research aim was to explore the cultural factors influencing perceptions of TB and their effect upon treatment adherence.  The following research questions were formulated:  How is TB perceived?  How does this perception affect acceptance of TB diagnosis and treatment?  What are the social consequences of being a TB patient and how do these affect treatment compliance?  Is treatment cost a major reason for defaulting?  How does pregnancy affect treatment acceptance and compliance?

Q7_TheoBas:
Barnhoorn and Adriaanse developed a TB compliance model, inspired by the Health Belief Model. In this model, TB treatment compliance is directly determined by health beliefs, support mechanisms and barriers; while socioeconomic and demographic factors play an indirect role.

Q8_SampCom:
48 hospital TB patients  (6 f.g. with 8 ppts each)

Q10_AduIntl:
Punjabi-speaking patients; 86% Muslim, 14% Christian

Q14_Desc:
A focus group discussion study was carried out to gain a better understanding of the impact of social stigmatization, treatment cost and pregnancy on defaulting. The study population consisted of 3 male and 3 female focus groups each with 8 hospitalized TB patients in Sialkot, Pakistan. The study was conducted to gain a better understanding of the impact of social stigmatization, treatment cost and pregnancy on defaulting.

Q15_Outc:
The study shows that TB is perceived as a very dangerous, infectious and incurable disease. This perception has many social consequences: stigmatization and social isolation of TB patients and their families: diminished marriage prospects for young TB patients, and even for their family members. Due to fear patients often deny the diagnosis and reject the treatment. While both male and female TB patients face many social and economical problems, female patients are more affected. Divorce and broken engagements seem to occur more often in female patients. Females are usually economically dependent on their husbands and family in law, and need their cooperation to avail of treatment. The belief that pregnancy enhances the risk for relapse decreases their marriage prospects. Pregnancy is also a reason for stopping TB treatment, as both are considered incompatible.

Q16_Limt:
The initial intention was to have as well a focus group composed of readmitted defaulters.  This could not be fully realized, however, as many of the readmitted defaulters were too sick to participate in the focus group discussion sessions.  The qualitative method of this study has overcome the limitations of a retrospective study and of a closed fixed response method of interviewing.  The inability to generalize the findings of this type of research to the population of interest is a recognized drawback of focus group methods.  The possibility of selection bias must be considered, as participants of the focus group discussions were limited to hospitalized TB patients in the initial phase of their treatment.  Three researchers independently analyzed the focus group discussion contents and their findings were very consistent.  The focus group discussion interpretations may be considered reliable.

Q17_Conc:
The findings of this study reveal the urgent need for a health education campaign to convince the general population that tuberculosis is curable. Uncertainties about the fact that TB is curable prevail widely and contribute to the social stigmatization of TB patients.

Q18_Recc:
A focus group discussion study should be repeated with several other groups that are carefully selected to be really representative of the target population.  All health care providers should act as destigmatizers.  Health education should become an integral part of the TB program.  Major emphasis should be placed on the curability of the disease. All uncertainties concerning TB and its treatment should be identified and addressed.  The psychological and social implications of TB diagnosis merit special attention.  Health education implies education of both patient and medical staff.  Only then we will be able to improve mutual understanding and co-operation, and ultimately improve success in our TB control efforts.


Q1_Title:
Initial Drug Regimens for the Treatment of Tuberculosis: Evaluation of Physician Prescribing Practices in New Jersey, 1994 to 1995

Q2_Key:
drug regimen, physician practice, treatment, TB, surveillance

Q6_ReQue:
The study objective was to evaluate MD Prescribing practices for the initial therapy for TB according to recommendations from both the CDC and the ATS.

Q14_Desc:
Study of statewide TB surveillance system in NJ from 1994-1995. Analysis was conducted on 1,230 TB patients who were alive at diagnosis and whose isolates were tested for isoniazid susceptibility.

Q15_Outc:
Almost all TB patients were reported from counties with an isoniazid-resistant proportion of at least 4%. One third of patients were not initially treated with four or more drugs. Multivariate analyses found that non-Hispanic white patients were more likely to be treated with fewer than four drugs than were non-Hispanic black patients. Private MDs and doctors at chest clinics were 5 times more likely to prescribe fewer than four drugs initially, as compared to doctors at a hospital where a national TB center is located.

Q17_Conc:
A substantial proportion of MDs did not initially treat their TB patients according to the CDC/ATS recommendations, suggesting that MDs in New Jersey should be better informed about the recommendation and the high level of drug resistance in the communities they serve, to assure that TB patients receive appropriate initial therapy.

Q18_Recc:
These results suggest that MDs should be further educated about the CDC/ATS recommendations and the high proportion of drug resistant TB in the communities they serve, to assure that people with TB receive appropriate initial therapy.


Q1_Title:
Development of Housing Programs to Aid in the Treatment of Tuberculosis in Homeless Individuals: A Pilot Study

Q1_Author:
LoBue, P., Cass, R., Lobo, D., Moser, K., & Catanzaro, A.

Q2_Key:
directly observed therapy, homelessness, supervised housing, TB.

Q3a_Other:
Cost and effectiveness research related to a housing intervention

Q6_ReQue:
Objective was to “describe experiences with novel supervised housing programs developed to aid in the treatment of TB in homeless individuals…”

Q8_SampCom:
25 patients whose charts were available and met criteria for homelessness

Q12_Oth:
Homeless shelters community-funded  housing for TB

Q14_Desc:
The article discusses the results of a retrospective chart review of homeless TB patients in supervised housing programs.  Using the computer database, the medical records of 25 homeless patients in two supervised housing facilities (one for infectious patients, one for non-infectious) was analyzed for microbiologic conversion and treatment completion.

Q15_Outc:
All patients in the infectious supervised housing programs successfully completed treatment and 85% of those in the non-infectious program completed treatment.

The estimated cost savings for infectious patients placed in supervised housing during treatment was over $27,000 per patient.

Q16_Limt:
Minor caveats are discussed based on the small sample size of the study.

Q17_Conc:
The data “suggest that implementation of housing programs in conjunction with the use of DOT is effective in improving TB therapy outcomes.”

Q18_Recc:
Larger, multi-center studies of similar programs are warranted to better determine and confirm the full effect and cost savings of this type of intervention.


Q1_Title:
Management of tuberculosis in San Diego County: A survey of physicians' knowledge, attitudes, and practices

Q2_Key:
TB, survey, knowledge, attitudes, practices, guidelines, physicians, adherence

Q6_ReQue:
The objective of this study was to assess local physicians’ knowledge, attitudes and practices regarding TB.

Q14_Desc:
A survey to assess physician knowledge was administered.  The survey consisted of questions covering the diagnosis and treatment of active disease, diagnosis and treatment of LBTI, and infection control.  The survey was sent to physicians who reported a TB case or suspected case to the local health department in the years 1995 to 1997.

Q15_Outc:
Of the 384 physicians in this group, 150 (39%) returned the survey form.  The percentage of physicians whose response conformed to health department guidelines varied widely from question to question (51% to 94%, median 83%).  Pulmonary medicine and infectious diseases specialists, physicians educated completely in the US, and physicians who treated 6 or more TB patients in the past 2 years were more likely to give answers in agreement with health department policies.

Q17_Conc:
Because the response rate to the survey was low, these findings may not be completely representative of the targeted physicians.  Nevertheless, they may indicate that health care provider education about TB management standards are needed.

Q18_Recc:
Future practices should involve health department assessments of local physicians’ knowledge, attitudes, and practices regarding this disease.  Thus, deficiencies can be identified and educational programs can be developed to improve patient management.


Q1_Title:
Delay and discontinuity - a survey of TB patients' search of a diagnosis in a diversified health care system

Q1_Author:
Lonnroth, K., Thuong, L., Linh, P., & Diwan, V.

Q2_Key:
TB, private healthcare, diagnostic delay, adherence

Q6_ReQue:
To describe delay to diagnosis; to compare diagnostic procedures and referral routines used by private and public health care providers; and to examine associations between contact with various types of providers and risk of delay to TB diagnosis

Q8_SampCom:
801 participants: 442 diagnoses cases of TB

Q14_Desc:
This is a cross-sectional survey of new patients in the National TB Program (NTP) of Vietnam.  Utilized a retrospective assessment of health seeking and diagnostic procedures used by previously contacted health care providers in order to determine diagnostic delay.  Four types of delay to diagnosis were defined.  Total delay, patient delay, provider delay and DTU delay.

Q15_Outc:
Four weeks after first symptom, 81% of patients had sought help outside the household.  Four weeks after first health care contact, 47% had been diagnosed with TB.  Private physicians used x-rays, sputum smears and referrals significantly less often than public health care providers.  Patients who had turned first to a private pharmacy, a private physician or a public hospital were significantly more likely to have a long provider delay then those who first turned to the NTP.

Q16_Limt:
This sample does not include TB patients who have completed treatment in the private sector.  Thus we have no knowledge about those who do not turn to the NTP.  Another methodological problem is that some contacts with providers had taken place many months before the time of interview.  Recall bias is a potential source of bias for estimates of delays and reported activities.

Q17_Conc:
Delay to diagnosis of TB in HCMC is due to inability among health care providers to detect TB than to under-utilization of health care services.  Diagnostic procedures need to be improved and referral chains need to be strengthened in HCMC, particularly among private providers.


Q1_Title:
Can I afford free treatment?: Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam

Q1_Author:
Lonnroth, K., Tran, T., Thuong, L., Quy, H., & Diwan, V.

Q2_Key:
Control, private healthcare, health-seeking behavior, DOT, Vietnam

Q6_ReQue:
Objective:  To explore health-seeking behaviors among people with TB, applying a specific focus on reasons for choices of private versus public health care providers

Q7_TheoBas:
Strauss and Corbin’s interpretation of Grounded Theory.

Q14_Desc:
The aim of this study was to investigate peoples’ health-seeking behaviors with regard to the choices they make between private or public providers of ambulatory TB treatment.  The authors studied attitudes towards private providers and the National TB Control Program (NTP) among people with TB.  More specifically, the authors analyzed perceived consequences of various health provider choices in order to identify provider characteristics that are of importance for patients when making health provider choices.

The authors conducted 26 interviews in Vietnamese.  The authors included people who were treated by all main providers of TB care in Vietnam.

Q15_Outc:
Health provider choices seem to be related to perceptions of how different provider characteristics are related to positive and negative consequences of treatment.  Three particularly important variables of provider characteristics, which seem to be closely linked to the patients’ health provider choices, have been identified, namely:  case-management strategy, setting, and payment mechanisms.  The authors assigned the following values for the NTP and self-employed private physicians, respectively:  use of protocols vs. flexible case management; treatment in a public vs. private arena; and free treatment vs. fee-for-service payment directly by patients.  

There were only two clearly positive aspects of the NTP from the interviewees’ perspective:  that use of strict protocols was associated with perceived higher chance of cure, and that treatment free of charge was associated with perceived better chance to contain costs.  In contrast, there were many perceived positive aspects of private TB care, particularly with regards to consequences related to privacy, convenience, and the possibility to avoid “social welfare stigma.”

Q16_Limt:
This study includes a small non-random sample of people with TB in one urban area in Vietnam.  All interviewees but one were under treatment at the time of the interview.  Generalizing the findings to all people with TB in Vietnam should therefore be done with caution.  Interviewing a person in the health service in which the person is currently under treatment may lead to bias in the responses regarding this particular health service.  However, the authors found that the different interviewees had rather similar attitudes towards a particular provider regardless of place of interview.

Q17_Conc:
People with TB in HCMC associate the structure of the NTP with a high chance of cure and with a possibility to contain cost.  However, when other aspects of quality of care are considered, the NTP appears less attractive than private or semi-private providers. About half of all persons with TB in Ho Chi Minh City initially opt for a private provider, and about 30 to 40 percent of all TB treatment is provided by private or semi-private providers.  Thus, the perceived positive aspects of private TB care outweigh the perceived positive aspects of the NTP for many patients.

There is an obvious and strong public health logic to the NTP strategy in Vietnam.  Supervised treatment that is believed to give better treatment outcomes than non-supervised treatment has been implemented widely.  When putting public health in focus, the NTP strategy seems to deliver the most rational care for TB.

But people do not choose health care providers based on public health concerns, they make decisions based on their individual perceived needs.  From the findings in this study, it could be argued that a too narrow focus on public health objectives within national TB control programs may be counterproductive for the control of TB.  A crucial point for the planning of an effective TB control program is to take account of individuals’ perceived needs as well as public health objectives.

Q18_Recc:
The authors believe that National TB Control Programs could take a number of measures to make its’ services more attractive to people, without having to compromise a clear public health focus.  The authors recommend that the National TB Control Programs consider:
	making DOT as little time-consuming and bureaucratic for patients as possible;
	making a strong effort to explain carefully to patients the rationale for DOT, as well as other complex diagnostic procedures, and any administrative procedures used in the diagnosis and monitoring of treatment;
	structuring outpatient departments and TB clinics in a way that promotes privacy for patients;
	educating health staff in how to perform the tasks outlined above;
	structuring health education in a way that it not only decreases the stigma of tuberculosis in the community but also decreases possible stigma of government-run and-subsidized programs.


Q1_Title:
Pitfalls in the Care of Patients With Tuberculosis

Q1_Journal:
The Journal of the American Medical Association

Q6_ReQue:
To determine, among a group of patients with multidrug-resistant pulmonary tuberculosis, whether there had been management practices that deviated from established guidelines, and whether these decisions were associated with the acquisition of multidrug resistance and adverse medical sequelae.

Q9_Other:
Mycobacteriology data; additional information obtained from patients by one investigator

Q13_Comm:
t-test for normal distribution, Fisher’s Exact Test (dichotomous) and Wilcoxon Rank Sum test (continuous); null hypothesis was rejected at P value of less than 0.05. Data are presented as mean and SEM.

Q14_Desc:
A review of TB patient records to determine whether management practices had deviated from established guidelines, and if these decisions were associated with MDRTB acquisition and adverse medical events.

Q15_Outc:
Among the 35 study patients, errors were detected in the management decisions in 28; there was an average of 3.93 errors per patient. The most common errors were the addition of a single drug to a failing regimen, failure to identify preexisting or acquired drug resistance, initiation of an inadequate primary regimen, failure to identify and address noncompliance, and inappropriate isoniazid preventive therapy. The multidrug resistance acquired through the errors resulted in prolonged hospitalizations, treatment with more toxic drugs, and high-risk resectional surgery. The costs for this "salvage therapy" were extraordinary, averaging $180,000 per patient.

Q17_Conc:
Aggressive professional education, tighter control on the provisions of care for tuberculosis patients, and the committing of additional resources to tuberculosis control programs are vital in improving the care of tuberculosis patients and limiting the development of acquired drug resistance.

Q18_Recc:
(1) Initial chemotherapy regimen for majority of patients should include at least 4 drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) a regimen of proven efficacy and limited toxic effects.
(2) Routine susceptibility testing should be performed on all new isolates of TB.
(3) When drug resistance has been identified, consult with specialists for treatment options.
(4) DOT should be provided in situations when noncompliance is demonstrated or likely.


Q1_Title:
Incentives vs Outreach Workers for Latent Tuberculosis Treatment in Drug Users

Q1_Author:
Malotte, C., Hollingshead, J., & Larro, M.

Q2_Key:
health behavior; motivation; patient compliance; substance-related disorders; TB

Q3b_Both:
This article focused on patient adherence through the use of several incentives, such as outreach worker provision (systematic social support) and monetary incentives.

Q6_ReQue:
To compare the independent and combined effects of monetary incentives and outreach worker provision of DOT for LTBI treatment in a sample of active drug users.

Q12_Oth:
community outreach program (storefront facility)

Q14_Desc:
The study compared the independent and combined effects of outreach workers and small monetary incentives in completion of DOT for LTBI by out-of-treatment drug users.  Participants were randomly assigned to one of three conditions for this study: 1) The most intensive approach was twice weekly DOT supplied by the study outreach worker at a location chosen by the participant, and the provision of $5 incentive at each visit; 2) The same condition as 1 but no monetary incentive; and 3) twice weekly DOT supplied at the study community site plus $5 monetary incentive for each visit.

Q15_Outc:
The percentage of medication taken was higher for those who received incentives, either with (71%) or without (68%) active outreach compared to those with active outreach alone (13%).  Treatment completion rates for each group included, Condition 1 = 53%; Condition 2 = 4%; and Condition 3 = 60%.

Q17_Conc:
Incentives were more effective than outreach worker provision of medications alone.  The combination of monetary incentives and an outreach worker did not increase treatment completion when compared to the use of incentives alone.

Q18_Recc:
Program managers should seriously consider the use of small monetary incentives in their TB control programs.


Q1_Title:
Monetary Versus Nonmonetary Incentives for TB Skin Test Reading Among Drug Users

Q1_Author:
Malotte, C., Hollingshead, J., & Rhodes, F.

Q2_Key:
TB, tuberculin test, crack cocaine, substance abuse, compliance, intravenous, incentives

Q3b_Both:
The study is testing internal (behavior change and incentives) and external stressor (drug use) relationship to TB

Q6_ReQue:
The purpose of this study was to compare the effects of monetary versus nonmonetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of newly recruited active injection and crack cocaine users, and to determine the prevalence of TB infection in this sample.

Q8_SampCom:
1078 active drug users randomized into 5 treatment groups:
$10 Cash group (n=217)
$10 grocery coupon group (n=217)
$10 Bus/Fast food group (n=218)
Motivational education group (n=211)
No incentive (n=215)

Q10_AduUSBrn:
Native American, African American, Caucasian

Q14_Desc:
Between 10/95 and 10/97, 1078 active injection and/or crack cocaine users, recruited using street outreach techniques, were skin tested for TB.  They were then randomly assigned to 1 of 5 experimental treatment conditions $10 Cash group (n=217), $10 grocery coupon group (n=217), $10 Bus/Fast food group (n=218), Motivational education group (n=211), No incentive (n=215).  All incentives were provided at the time of return for skin test reading.

Q15_Outc:
95% of those who received $10 returned for skin test reading compared to 86% of those who received grocery store coupons and 83% of those who received either bus tokens or fast food coupons.  In contrast, only 47% of those who received the educational session and only 49% of those who received usual encouragement returned for skin test reading.  The prevalence of positive TB test was 21%, and was similar for crack cocaine and injection drug users.

Q16_Limt:
A potential limitation of this study, is that a majority of the participants had previously been in an earlier HIV risk-reduction study in which participants were paid for follow up assessment, and they might have had a different response to incentives and education than newly recruited individuals.

Q17_Conc:
Nonmonetary and monetary incentive dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection.  Nonmonetary incentives were somewhat less effective than monetary incentives.


Q1_Title:
Tuberculosis screening and compliance with return skin test reading among drug users

Q3b_Both:
The study tested internal (behavior change and incentives) and external stressors (drug use) relationship to TB

Q6_ReQue:
The study assessed the independent and combined effects of different levels of monetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of active injection and crack cocaine users.  The prevalence of TB infection in this sample was also determined.

Q8_SampCom:
Condition 1: Motivational education and $10 (n=203); Condition 2: Motivational education and $5 (n=198); Condition 3: Motivational education only (n=99); Condition 4: No incentive (n=100); Condition 5: $5 Cash (n=204); Condition 6: $10 Cash (n=200)

Q14_Desc:
Between 4/94 and 8/95, 1004 active injection and/or crack cocaine users, recruited using street outreach techniques, were skin tested for TB.  They were then randomly assigned to 1 of 6 experimental treatment conditions: Motivational education and $10 (n=203); Motivational education and $5 (n=198); Motivational education only (n=99); No incentive (n=100); $5 Cash (n=204); $10 Cash (n=200).  All incentives were provided at the time of return for skin test reading.

Q15_Outc:
More that 90% of those who received $10 returned for skin test reading compared to 85% of those who received $5 and 33% of those who received no monetary incentive.  The education sessions had no impact on return of skin testing.  The prevalence of a positive TB test was 18.3%.

Q17_Conc:
Monetary incentives dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection.


Q1_Title:
Socioeconomic deprivation and notification rates for tuberculosis in London during 1982-91

Q1_Author:
Mangtani, P., Jolley, D., Watson, J., & Rodrigues, L.

Q2_Key:
TB, socioeconomic, deprivation, poverty, notification rates

Q6_ReQue:
To investigate the association between four sociodemographic measures (unemployment, overcrowding, low social class, and the proportion of migrants from areas of high prevalence of TB) and average level and rate of change of notification rates for TB.

Q14_Desc:
Ecological analysis of both the average and the rate of change of standardized (indirect) annual notification rates for TB from 1982 to 1991 and sociodemographic measures form 1981 to 1991 censuses in the 32 London boroughs.

Q15_Outc:
The average level of notification was correlated with overcrowding and the proportion of migrants but not with unemployment or social class.  No significant association was found between the rate of change in notification rates and sociodemographic measures in 1981.  An association was found between increases in unemployment and the rate of change in notification rates, but the effect was small.  Changes in the levels of unemployment explained 23% of the variation between boroughs in the rate of change in their notification rates.

Q16_Limt:
It is possible the study was lacking in power to detect a separate but weak association with unemployment and social status.  Changes in the trends in notification rates since 1982 may be due to an artifact.  Changes over time in the percentage of cases notified or ascertained in each borough may be obscuring some of the association between risk factors investigated and trends in notification.

Q17_Conc:
The average TB notification rates were related to overcrowding and the proportion for migrants in 1981.  Only increases in unemployment from 1981 to 1991, however, were significantly associated with the rate of change in notifications over the same period.

Q18_Recc:
Further studies are needed to investigate why the rates have stopped declining.  These include studies to validate the notification rates, analyses with concurrent and individual measures of deprivation and risks of TB, and confirmation and clarification of the contribution from unemployment or associated factors.


Q1_Title:
Knowledge of tuberculosis in high-risk populations: Survey of inner city minorities

Q1_Author:
Marinac, J., McBride, D., Hamburger, S., & Willsie, S.

Q2_Key:
TB, Knowledge, survey, educational programs, high-risk, minorities

Q6_ReQue:
To determine the baseline knowledge about TB in at risk minority individuals.

Q8_SampCom:
505 Total.  African Amer: 490, Hispanic: 6, American Indian: 5, Hawaiian: 1, Vietnamese: 1

Q10_AduUSBrn:
African American: 490, Hispanic: 6, American Indian: 5, Hawaiian: 1, Vietnamese: 1

Q10_AduFrBrn:
7 individuals were foreign born  (race/eth unspecified).

Q13_Comm:
Chi-Square test and ANOVA used, Significance = .05

Q14_Desc:
The study was designed to determine the knowledge base of minority (non-Caucasian, 342 females, 163 males) individuals within the metropolitan Kansas City area concerning the etiology, transmission, risk factors, symptoms, and treatments of TB.  Face-to-face surveys were conducted with 505 adult minority participants who were visiting, employed by, or receiving medical care at 3 health centers in the Kansas City Metropolitan area.  (Health care providers were excluded from this study.)  This information will provide the foundation for future targeted community-based TB education programs.

Q15_Outc:
Most participants (97%) were African-American, with 57% between the ages of 21-40.  Over two-thirds were high school graduates, and 77% reported an estimated total household annual income of <$20,000.  Self-perceived knowledge about TB was rated as “little” or “nothing” by 60% of respondents.  The overall correct response score was 61%, with 55% correct response to queries related to etiology, 53% for identification of high-risk populations, 57% for possible routes of transmission, 89% for symptoms, and 49% for treatment.  Males, those with annual incomes > $20,000, and individuals 51-70 years old had the highest scores.

Q17_Conc:
In this high-risk inner city population surveyed, knowledge deficits in the etiology, transmission, and treatment of TB were identified. The results of this survey indicate that educational efforts directed at the etiology, transmission, and treatment of TB are needed in this targeted high-risk population.  The health department, television, and the workplace were identified as their preference for information sources.

Q18_Recc:
To be successful, any education program must begin with an understanding of the knowledge base of participants, so that erroneous perceptions and beliefs can be corrected and the knowledge base can be expanded.  Since the morbidity and mortality of congenital TB is high, the area will be a target of future educational efforts. These findings will be used in the next phase to develop educational programs directed at reducing the incidence of active TB cases and increasing preventative interventions.


Q1_Title:
Integrating the Client's Perspective in Planning a Tuberculosis Education and Treatment Program in Honduras

Q3b_Both:
Internal influences such as barriers to treatment knowledge, attitudes and beliefs were assessed, as were health system delays and changes to TB control programs (external).

Q6_ReQue:
The investigation team formulated the following objectives:
1.Determine why some patients with respiratory symptoms do not want the appropriate tests.
2.Determine why a high percentage of patients with respiratory symptoms who are tested never return to pick up the results.  
3.Determine why a percentage of those whose tests are positive do not begin treatment.
4.Determine why a percentage of patients who do begin treatment do not complete it.
A series of 6 hypotheses that refer to the client’s perspective were created.

Q8_SampCom:
526 =  361 healthy adults in nine different communities three different regions of the country, and 75 TB patients, 55 relatives of patients, 20 health personnel, 12 nurses in 12 health centers, and 3 epidemiologists in charge of regional TB programs.

Q10_AduIntl:
No race/ethnicity specified of participants in Honduras

Q12_Oth:
Health departments  --   Regional TB programs

Q14_Desc:
A baseline investigation was conducted to determine the knowledge, attitudes and behaviors of the public, patients and patients’ relatives with regard to tuberculosis in Honduras.  Data were gathered using surveys (healthy population), focus groups (healthy population, patients) unstructured interviews (relatives, health personnel, nurses and epidemiologists) and focused interviews (relatives).  Based on these findings, An educational campaign was implemented to inform the population at large that TB patients no longer transmit the disease, that they can be completely cured if treatment is begun promptly, and that a persistent cough lasting for >15 days may be a symptom.

Q15_Outc:
The baseline investigation confirmed the existence of social rejection toward tuberculosis.  Three underlying reasons for health seeking at health center were discussed:  1) the populations recognize the disease only in its advanced stage, when primary symptoms are accompanied by others that seriously affect the patient’s normal life.  2) The population is reluctant to accept the sputum sample as a method for detecting such an important disease as TB. 3) Even when the patient can no longer ignore the evidence of symptoms and admits that the nurse’s suspicions might be correct, they are willing to die rather than undergo treatment.  Several problems were detected in the diagnosis of respiratory cases, e.g., difficulties leading to long delays in the collection and analysis of sputum samples and in the subsequent reporting of the findings. Moreover, instructions given to the patient are quite vague as to exactly what quality sputum is needed and how best to obtain it.

Based on the evaluation of the 3 educational campaign messages, a high percentage of the population (85%) remembered and believed the messages.  Several health centers reported an increase in sputum test requests as a result of the campaign.

Q16_Limt:
The unstructured interview method produced results that are difficult to tally, but very useful in small samples.  According to the authors, it was still too early to evaluate the total effect of the educational campaign, as most graphic materials were still being distributed at the time the article was being written.

Q17_Conc:
An understanding of and familiarity with the client's perspective can help educational programmers identify exactly which facts or opinions must be reinforced or modified so that beneficial health services are utilized.  The most important conclusions were as follows: 1) Opinions, knowledge, and attitudes of the population regarding a disease are decisive factors in the effective use of the health centers available for its treatment.  2) When a health program is going to be initiated, planned or redesigned, it is of utmost importance to investigate the target population.  3) When an informative educational campaign is carried out in the mass media, it must be accompanied by an improvement in the organization and availability of the services referred to.  4) The point of view of the population that uses the health services must always be taken into consideration by planners, administrators, and all others in charge of health services.


Q1_Title:
Delayed Diagnosis of Pulmonary Tuberculosis in City Hospitals

Q1_Author:
Mathur, P., Sacks, L., Auten, G., Sall, R., Levy, C., & Gordin, F.

Q2_Key:
Delayed diagnosis, Washington, D.C., older age

Q6_ReQue:
Objective:  To examine the clinical acumen of the medical staff in the diagnosis of tuberculosis and investigate the reasons for delay in the identification and treatment of patients with pulmonary tuberculosis.

Q13_Comm:
For descriptive and analytic statistics, the X2 and Student’s t test were used.

Q14_Desc:
The authors of this paper undertook this study in two Washington, D.C. hospitals to examine the factors that cause delay in the recognition and treatment of pulmonary tuberculosis.  A retrospective chart review was undertaken between July 1985 and June 1988 on all patients with culture-proven pulmonary tuberculosis at two inner city hospitals.  The authors determined the time intervals between admission and the clinical suspicion, diagnosis, and treatment of tuberculosis.  They evaluated the clinical features for their effect on these time intervals.

Q15_Outc:
Eighty-five patients with culture-proven pulmonary tuberculosis were identified.  Tuberculosis was suspected in 36 patients on admission.  By the end of one week, tuberculosis was confirmed in 50 patients and suspected in 23 others.  Twenty percent of patients either died or were discharged before the diagnosis of tuberculosis was made.  Older patients (>65 years) were misdiagnosed more commonly than younger patients (82% versus 48%).  Patients without respiratory symptoms were misdiagnosed more frequently (78% versus 49%) than were those with symptoms.  Other reasons for delayed diagnosis and treatment included low use of tuberculin skin tests, misinterpretation of unusual chest roentgenograms, and waiting for culture results in patients with negative acid-fast smears.

Q17_Conc:
The authors conclude that pulmonary tuberculosis is often unsuspected and frequently misdiagnosed, which results in appreciable delays in therapy.  Diagnosis is most difficult in elderly patients and those without respiratory symptoms.  Under-use of tuberculin skin testing and misinterpretation of chest roentgenograms also contribute to the time lag in establishing the diagnosis of pulmonary tuberculosis.  Even when tuberculosis is suspected, treatment is often considerably delayed while bacteriological confirmation is awaited.  It is therefore imperative that clinicians develop improved skills in suspecting active tuberculosis so that early treatment and proper infection control measures can be implemented.

Q18_Recc:
Among the patients who were suspected of having active tuberculosis, there was a substantial time lag in the institution of therapy.  Although tuberculosis was suspected in 66 of the 85 patients within 48 hours of admission, more than four weeks had elapsed before an equivalent number of patients received therapy.  Much of this delay was ascribed to the reluctance of physicians to institute therapy before bacteriologic confirmation of the disease (either by smear or culture) was obtained.  Reducing this delay is crucial in preventing the nosocomial transmission of tuberculosis not only to other susceptible patients, but also to hospital employees who may be at risk.

In initiating therapy, less reliance should be placed on negative sputum smears, as waiting for a positive culture result may lead to considerable additional delay before treatment is begun.  In this regard, some investigators favor early initiation of empiric therapy in patients where active pulmonary tuberculosis is suspected.  Other investigators have suggested the use of more aggressive diagnostic measures, such as fiberoptic bronchoscopy with bronchoalveolar lavage and/or transbronchial biopsy, if sputum smears are unhelpful.  New rapid diagnostic tests including polymerase chain reaction and DNA hybridization show promise in addressing this problem and may supplant insensitive sputum smears and laborious culture techniques.


Q1_Title:
Knowledge and Attitude of Tuberculosis Patients Towards Their Disease and Its Management

Q1_Author:
Mathuria, B., Jain, N., Jhamaria, J., Luhadia, S., Madan, A., Sharma, T., & Mathur, D.

Q2_Key:
India, patients, knowledge, symptoms, treatment

Q6_ReQue:
Objective:  The present study was undertaken to evaluate the factors that prompt the infectious patients to seek medical advice as well as his knowledge about tuberculosis and its management.

Q14_Desc:
A total of 300 sputum positive patients of pulmonary tuberculosis were interviewed to evaluate the factors that prompted them to seek medical advice, as well as to study their knowledge about tuberculosis, its management and prevention.  The interview protocol included topics regarding:  (1) patients’ awareness of symptoms of pulmonary tuberculosis and action taken by patients; (2) aetiology, transmission, manifestations, diagnosis, and treatment of pulmonary TB; and (3) preventive and control measures of the disease.

Q15_Outc:
A large number of patients knew that cough (97.3%), gradual weakness (88%), fever (81.3%), spitting of blood (66.6%), breathlessness (65.3%), loss of weight (56%), and chest pain (44%) can be symptoms of tuberculosis.  Almost half of the patients (49%) felt that coughing was the mode of transmission.  Ninety-two percent knew that disease is curable and 91% opined that drugs alone can treat tuberculosis.  But only 14% related its aetiology to a specific germ.  None of the patients knew that sputum examination alone could also be helpful in diagnosis.  Eighty-five percent stressed upon hospitalization for treatment and 39% upon good nourishment.  Only 9.6% knew about BCG vaccination and 28% were unaware about district tuberculosis centers and the National Tuberculosis Control Programme.  Thirty-seven percent had no idea about the duration of treatment.  Forty percent thought that it should be between 1.5 and 2 years.  Seventy-six per cent of patients were of the view that treatment should be taken regularly.  According to 63%, a response to treatment could be judged by clinical improvement.

Q17_Conc:
A majority of patients in the present study knew about symptoms of tuberculosis, but only 14% of the patients knew that specific germs cause tuberculosis.  This distinctly brings out a gross difference between awareness about tuberculosis on the one hand and the attitudes and behavior of these patients towards the disease on the other hand.  Sociological enquiries into the awareness of chest symptoms in other studies have also provided strongly suggestive evidence that symptoms are usually sufficient to induce the patients to seek relief by contacting existing health services.

Q18_Recc:
In an attempt to improve this situation, the authors offered the following suggestions:
1) Mass media should be used to impart health education about common symptoms, methods of diagnosis, advantages of early detection, and treatment and prevention of the disease in local languages.
2) People should not only be informed about early symptoms and signs of tuberculosis, but should be told that the disease is caused by specific germs that can be diagnosed easily at nearby primary health centers or dispensaries with the help of a sputum examination.  People should also be told that tuberculosis can be treated at home effectively and safely, and can be cured with specific drugs.
3) Medical, paramedical, and ancillary persons who deal with the problem of TB should be given periodic short refresher course.
4) Patients from economically poor rural areas should be provided with some financial assistance or travel arrangements.

For a complete list of recommendations, see page 68.


Q1_Title:
Community Collaboration:  Prevention and Control of Tuberculosis in a Homeless Shelter

Q1_Author:
Mayo, K., White, S., Oates, S., & Franklin, F.

Q2_Key:
homeless, directly observed therapy (DOT), prevention, nurses, HIV

Q6_ReQue:
Objective:  This article describes an epidemiologic study of the problem of TB among a population of sheltered homeless, with attention given to the effectiveness of measures to prevent and control TB, and the learning opportunities provided for nursing students during a community health nursing practicum

Q13_Comm:
The authors did not perform tests for statistical significance

Q14_Desc:
An urban shelter in Charleston, South Carolina developed and began a tuberculosis prevention and control plan that addressed the priorities recommended by the CDC.  After an increase in TB in the shelter in 1992, the local health department, the homeless clinic nurse practitioners, and Medical University of South Carolina College of Nursing faculty and students collaborated with the shelter staff to provide initial mass screenings for contact investigation.  They also developed and implemented new polices and procedures for an ongoing TB prevention and control program.  The new policies required that guests obtain screening for TB within 7 days of arrival at the shelter and every 6 months thereafter.  Also, a public health nurse began providing directly observed therapy twice weekly at the shelter.

Q15_Outc:
Of the 22 persons who started preventive therapy in February 1993, 17 (77%) completed 6 months of treatment and five did not complete treatment.  Of the five who did not complete therapy, three left with no forwarding address, two of whom had stopped drinking and found full-time jobs.  Two were taken off treatment for failure to take the medication regularly and for continued substance abuse.

Q17_Conc:
The program described in this paper contributed to the reduction of TB infection and disease in an urban homeless shelter in South Carolina.  The mass-screening process was complicated and required collaboration among shelter staff, public health nurses, nursing faculty and students, and community agencies.  The management of mass screening and the process of collaboration described in this paper could be useful to nurses working in shelters and other congregate settings with populations at risk for TB.

The clinic nurses’ knowledge of individuals’ health history, including physical, mental, social, and environmental factors, was invaluable in supporting treatment decisions.  Another critical activity was TB education for guests and shelter staff.  Guests were taught why they needed to be tested, what the screening procedures involved, and the possible outcomes of screening.

Q18_Recc:
Nursing students should learn about communicable diseases and the role of the public health nurse in disease prevention, case-finding, early diagnosis and treatment, and follow-up.  (Nurse providers may experience frustration in attempting to convey the importance of TB testing to their clientele.  Involving clients completely in their care by informing them of the benefits and consequences associated with each stage of testing, diagnosis, and treatment, and consideration of their unique life circumstances conveys respect.)

Since patient outcomes are used to assess the quality of nursing care, nursing should develop effective and efficient delivery models.

Priorities for TB Prevention and Control Activities among Homeless Persons:
1)  The highest priority should be given to (a) detection, evaluation, and reporting of homeless persons who have current symptoms of active TB, and (b) completion of an appropriate course of treatment by those diagnosed with active TB.
2)  The second priority should be screening and preventive therapy for homeless persons who have, or are suspected of having HIV infection.
3)  The third priority should be the examination and appropriate treatment of persons with recent TB that has been inadequately treated.
4)  The fourth priority should be screening and appropriate treatment of persons exposed to an infectious (sputum-positive) case of TB.  Because contacts are difficult to define in a shelter population, screening all residents of a shelter when an infectious case is identified is usually necessary.
5)  The fifth priority should be screening and preventive therapy for homeless persons with known medical conditions that increase the risk of TB (e.g., diabetes mellitus).


Q1_Title:
Effects of Previous Medication Experience and Health Beliefs on Intended Compliance to an Imagined Regimen

Q2_Key:
TB, health beliefs, treatment compliance

Q6_ReQue:
“To determine the relationship among an individual’s beliefs and attitudes, prior medication experience, and intentions to comply with a medication regimen.”

Q7_TheoBas:
Health Belief Model and Health Locus of Control

Q8_SampCom:
Sample size (N)=  256 (undergraduate students, 36% male, mean age of 22, 71% white, 27% black, 2% “other race”)

Q13_Comm:
Several multiple regression analyses were performed with several variables showing statistical significance (see below).

Q14_Desc:
Article describes a research study with college students in which participants are asked to complete an 83-item questionnaire consisting of several psychosocial scales (Health Locus of Control, Health Belief items) and a measure of experience with medication regimens.  

Participants were then asked to imagine they had just been diagnosed with TB, and were then assessed with measures of perceived benefits, barriers, and likelihood of compliance with treatment. 

Regression analysis was used to determine predictors of likelihood of hypothetical compliance.

Q15_Outc:
Among individuals with no experience with medication regimens, the only variable related to compliance in the regression analysis was perceived barriers.  Among those who had prior experience with medication regimens, measures of benefits of action, chance locus of control and internal locus of control were predictive of compliance intentions.

Q16_Limt:
No specific limitations are cited, although reference is made to the presence of “several limitations”.

Q17_Conc:
Study supports other research linking Health Belief Model and Health Locus of Control to treatment compliance.  Novel results are the findings that prior medication experience act to mediate the effect of these variables on compliance.

Q18_Recc:
Prospective studies of compliance measuring these variables should be undertaken to further examine the relationships found in this study.


Q1_Title:
Using Peer Helpers for Tuberculosis Prevention

Q2_Key:
TB, international students, peer helpers, prevention

Q6_ReQue:
The goal of the study was to assess the effects of using peer helpers to improve TB prevention.

Q10_AduFrBrn:
China, Hong Kong, Taiwan, Singapore, India, Malaysia, Philippines, Korea, Japan, W. Europe, Australia, Canada, E. Europe, Middle East, Latin America, Sub-Saharan Africa, Pacific Islands

Q14_Desc:
The authors report on a novel and effective peer helper program initiated at the University of Iowa Student Health Services in fall 1992 to help prevent the development of active TB among foreign nationals attending the university.  The concept of the peer/advocate included advocating for the position of the patients, the broader university and the public health community.

Q15_Outc:
Before initiating the peer program, the rate of compliance with TB prevention (INH protocol) efforts for those students eligible for treatment was less than 5% (ranging from 5% to 14%).  Since the peer program was initiated, compliance has risen to 50%.  INH compliance rates have vastly improved, ranging from 62% to 79%.

Q17_Conc:
Given the dramatic improvement in compliance, the staff at the University of Iowa SHS have concluded that peer facilitators are a cost-effective, culturally appropriate means of increasing compliance with TB prevention.  In addition, though harder to measure, working with peers has had a positive effect throughout the student health clinic.  All staff, whether or not they are involved with the TB prevention program, enjoys a greater sensitivity to cross-cultural health issues.

Q18_Recc:
The program will be assessed to determine which components are most effective and in which areas efficiency can still be improved.  Area-wide TB control efforts also need to be expanded and coordinated to ensure that dependent family members are adequately screened and treated.  Use of the peer advocate model in other areas of healthcare.


Q1_Title:
Successful Supervised Ambulatory Management of Tuberculosis Treatment Failures

Q2_Key:
TB treatment, patient compliance, drug therapy

Q6_ReQue:
The study was undertaken to develop an effective and practical ambulatory program of TB management in patients requiring retreatment that could be extended to initial treatment-compliance problems. It was also designed to evaluate the response, compliance, and need for hospitalization of patients on supervised daily ambulatory treatment for the first 6 months of a 24 month treatment program.

Q9_Other:
Chest x-rays, biological samples (sputum and blood draws)

Q14_Desc:
Twenty-one patients with long histories of failed treatment for pulmonary tuberculosis, most of whom were recalcitrant in taking medications, were treated on a primarily ambulatory basis with various antituberculosis drugs. Supervision ensured that medication was taken. Convenient, personalized, comprehensive medical care and social services were provided without cost to patients during the early phase of treatment. Management during the continuation phase was unsupervised.

Q15_Outc:
Fourteen patients had drug-resistant tuberculosis and 16 were either alcohol or opiate abusers. Treatment success was achieved in 19 of 21 patients with a mean follow-up of 26 months (80% compliance rate). Two patients failed to achieve a sputum-negative status for Mycobacterium tuberculosis.

Q17_Conc:
This study reinforces previous contentions that most treatment-failure patients, even the recalcitrant, can be successfully treated on an ambulatory basis for pulmonary TB. Despite the overall good results with this method of treatment, it is clear that a very small number of patients will defy successful management in this manner.

Q18_Recc:
For the non-compliant TB patient, other strategies must be devised. Using an approach that intensifies comprehensive efforts during the early phase of treatment, there should be greater success in treatment, and thus a reduction in the need for renewed treatment.


Q1_Title:
Identifying Compliance Incentives for Screening and Treatment of Tuberculosis

Q2_Key:
TB, compliance, incentives, adherence, screening

Q6_ReQue:
To effectively control TB and to reduce the high rate of TB in the area, an ongoing screening program was instituted to identify individuals with TB and to initiate treatment.

Q14_Desc:
A significant proportion of the residents of the Downtown East Side in Vancouver, BC, Canada are at a comparatively high risk of contracting TB due to various psychosocial factors.  Based on the data from three case-finding studies of a small segment of this population, it was suspected that this area contained may undetected cases.  This article describes various strategies employed to encourage these individuals to be screened and also examines selected components of community health nursing practice utilized to determine what factors contribute to adherence to treatment.

Q15_Outc:
A total of 1276 persons attended the survey.  Of these, 1179 received a chest x-ray; 993 lived in the Skid Row area which was the target area for the survey.  14 active and 108 inactive cases of TB were identified.  1218 sputum samples were collected; 3 were positive bacteriologic on smear and 6 were positive on culture.  A total of 1186 TB skin tests were performed.  938 (79%) returned for reading.  Following the survey, a regular bi-monthly chest x-ray clinic was established in the area.  Based on the information described, successful interventions to improve adherence included those that are culturally and socially constructed in context with the client by negotiating with the scientific and popular perspectives.

Q17_Conc:
The strategies applied to encourage these individuals to be screened and to acquire the treatment for TB are based on the philosophy that the service must be accessible to them.  Clients bring their interpretations of the biomedical model and their beliefs and values derived from their sociocultural backgrounds to each encounter with the health care system.   It is necessary to have numerous and varied approaches to work with these people.  Both the client’s cultural beliefs and the practitioner’s explanations of illness and treatment exert a striking influence in the perceptions of the health care process and on the labeling of the client.


Q1_Title:
Antecedents of Adherence to Antituberculosis Therapy

Q2_Key:
TB, adherence, self care agency, therapy

Q3b_Both:
Medication adherence is viewed as a self-care behavior that is associated with and affected by certain characteristics of the health problem, the patient, and the health care system

Q6_ReQue:
The purpose of this study was to identify patient characteristics that are associated with adherence to anti-TB medications.

Q7_TheoBas:
The conceptual framework for this study was a merger of Orem’s self care deficit theory of nursing (Orem, 1991) and the model of adherence that DiMattteo and DiNicola (1982), and Gritz, DiMatteo, and Hays (1989) proposed.

Q11_USA:
Georgia:  north Georgia, southwest Georgia and Atlanta

Q14_Desc:
This correlational study identified antecedents of adherence to anti-TB therapy in a convenience sample of 62-English speaking adults.  From a demographic perspective, the study sample was similar to the referent population of TB patients in Georgia.  This study examined a combination of patient characteristics in a theory based multivariate manner using a combination of the beliefs and perceptions of this group as well as their self care capacity.

Q15_Outc:
The mean self-reported adherence score was 92.6%.  Higher levels of self-reported adherence were associated with an annual income of $11,000 or more, education beyond high school, no current alcohol use, perceived support and absence of barriers to medicine taking, strong intentions to adhere, and a high capacity for self-care.  Those six variables accounted for 28% of adherence variance, (p = 0.0017).  Additionally, belief in the usefulness and benefit of medications was strongly correlated with intentions to adhere (r = 0.83, p < 0.001), and interpersonal aspects of care was significantly correlated with perceptions of medication utility, (r = 0.65, p < 0.001), support/barriers (r = 0.44, p < 0.001), intentions (r = 0.69, p < 0.001), and self-care (r = - 0.42, p < 0.01).  Persons who were diagnosed with HIV reported significantly lower adherence.

Q16_Limt:
Relative homogeneity of the items; small number of the items on the TBGAS, PSV, PS and SB; misunderstanding of some of the items, especially the negatively worded statements; small sample sizes; and bias from non-random selectivity may contribute to lower alpha coefficients for these newly developed instruments.

Q17_Conc:
Cure of TB is contingent on adherence with the medication regimen.  Adherence to anti-TB medications is multidimensional, involving an interplay between sociodemographic variables, patient characteristics, and patient perceptions, nurses who provide care to TB patients must be aware of the complex nature of this behavior so that the appropriate assessments may be conducted, high risk patients identified, and interventions tailored to promote adherence

Q18_Recc:
Recommendations for further research include replication of this study on a larger sample with a wider variation in race and ethnicity, HIV coinfection, homelessness, and drug use and replication on non-English speaking persons, with attention to culturally and linguistically appropriate questionnaires for the predominately foreign born groups with TB.  Similar studies should be conducted using subjects with a broad range of health problems and who take long-term medications to ascertain whether a general model of generic predictors for medication adherence can be developed.  What TB patients consider support and barriers to taking medications should be examined, perhaps using qualitative methods.  Nursing interventions that promote adherence should be developed and tested.


Q1_Title:
Conceptions of Tuberculosis and Therapeutic Choices in Highland Chiapas, Mexico

Q2_Key:
TB, health seeking behavior, knowledge, culture, adherence

Q6_ReQue:
This article presents the views on TB and health seeking activities of several patients in the Tzeltal hamlet of Yochib.

Q14_Desc:
This article aims to clarify the influence of cultural beliefs on the Indians’ response to TB control programs.  Due to religious change and a prolonged contact with Western medicine, people in Yochib widely utilized the local outpatient clinic for the treatment of TB and other diseases.  During the year prior to the author’s fieldwork (1986) numerous patients received TB treatment at the clinic.  In-depth interviews with these patients provided fine grained data on illness perceptions and health care choices.  During a second phase of the fieldwork, the author closely followed three newly diagnosed patients and actively participated in their treatment.  The central interests of the research are the examinations of the cultural conceptions of TB viewed within the context of medical and social change.

Q15_Outc:
In this article the author analyzed patients’ responses to TB in a Tzeltal community that underwent sociocultural transformation.  In Yochib naturalistic conceptions of TB and faith in Western medicine promoted the utilization of the TB services offered by the local clinic.  But other factors, relating to patients’ perceptions of the disease’s onset and duration, appeared to hinder clinic utilization.  Patients’ confusion about the early symptoms of TB sometimes delayed their search for appropriate treatment.  The disappearance of symptoms at the end of the initial phase of treatment often led the patients to believe they were cured and discontinue therapy.

Q17_Conc:
Some general conclusions can be drawn from the study of adherence in Yochib.  As the partial success of the 1986 program shows, organizational problems at the institutional (macrosocial) level affect the functioning of peripheral services, and this in turn affects the microsocial level of the individual health care decisions.  While cultural conceptions inform or organize behavior, patient behavior also responds to service delivery factors.  Because of this interplay, health care factors need to be considered in conjunction with sociocultural factors when planning interventions or implementing programs.  Improved TB services can pave the way for interventions that address the cultural understandings of TB.  If educational interventions adapt their messages to the health beliefs and values of patients, they can contribute to the success of control programs, particularly by fostering more frequent use of diagnostic services and greater acceptance by patients of prolonged therapy.

Q18_Recc:
The need for studies that more thoroughly investigate the interaction of socioculture and health care factors.


Q1_Author:
Menzies D, Fanning, A., Yuan, L., & Fitzergerald, M.

Q2_Key:
health care workers, physicians, nurses, technicians, TB, nosocomial

Q6_ReQue:
The review attempts to synthesize the evidence, particularly where contradictory, regarding the risk of nosocomial transmission of TB to health care workers and the efficacy of the recommended measures for its control.

Q14_Desc:
A review of TB among health care workers using Medline database between 1966 -1994. All articles including cohort, case-control studies, and prevalence surveys were examined.

Q15_Outc:
Estimates of the risk of TB disease are 0.6 -2.0 risk ratios and estimates of risk of TB infection range from 0.2 -10%, depending on the hospital population (i.e., pulmonary fellows vs. all workers). Contributing factors to nosocomial transmission are delayed diagnosis; poor ventilation, bronchoscopy; dressing change; autopsy; drug-resistant strains; multiple lapses in administration, engineering, and personal infection-control practices. 

Evidence in support of recommended control measures include diagnosis and therapy; ventilation; UV light; masks; tuberculin screening; Bacilli Calmete-Guerin vaccination. After implementation of stringent measures to control infection the risk of TB declined among technicians in laboratories.

Q17_Conc:
Occupationally acquired TB varies considerably among and within institutions. Complete elimination is unrealistic and a more rational goal is to reduce the risk to the level of the general population.

Q18_Recc:
Every health care institution should develop an infection-control policy for TB and implement recommended measures for the institution’s estimated risk of nosocomial transmission. Hospitals should institute surveillance for all TB cases; testing of sputum should be available; workers should undergo two-step TB testing with Mantoux technique; HIV infected workers should avoid exposure to TB; and those hospitals admitting MDRTB should employ extra prevention measures. Finally, agreement on personal respirators for workers is needed.


Q1_Title:
Factors associated with compliance in treatment of tuberculosis.

Q1_Author:
Menzies, R., Rocher, I., & Vissandjee, B.

Q6_ReQue:
Objective:  To determine the proportion of patients who completed anti-tuberculosis therapy, and the personal characteristics, aspects of management, nursing assessments, and interventions associated with compliant behavior.

Q13_Comm:
Bivariate associations were tested for significance using chi-square for categorical, and t-test for continuous variables.  A P value of less than 0.05 was accepted as evidence of statistical significance.

Q14_Desc:
The authors conducted a retrospective review using the medical and nursing records of adult patients treated at the tuberculosis clinic of the Montreal Chest Hospital in 1987-1988.  The authors abstracted demographic data from hospital dossiers, as well as therapeutic information such as medications prescribed and duration, and follow-up data, including punctuality of clinic attendance and urine INH testing.  From nursing records, the authors abstracted information such as the language spoken by the patient, nursing assessments of the patient’s understanding of treatment, and the patient’s compliance with therapy during follow-up.

Q15_Outc:
In all 352 patients were identified, of whom 59% were judged to have completed therapy.  Completion of therapy was recorded in 92% of those with culture-positive disease, 76% of those with active but culture-negative disease, and 54% among those prescribed preventive therapy (P<0.001).  Compliance with preventive therapy was highest among those who had been in contact with an active case, and lowest among those identified through a workforce screening survey (P<0.01).  At the time of the first follow-up visit, patients identified to have suboptimal compliance were more likely to fail to complete therapy (P<0.001).  Compliance was higher among those initially hospitalized, those assessed to have better understanding (P<0.05), those prescribed 6-9 rather than 12 months of therapy (P<0.01), and those who returned for follow-up within 4 weeks of initiation of therapy (P<0.01).

Q16_Limt:
There are a number of limitations to this survey.  This survey was retrospective, so that information such as the nursing assessments was missing from a number of records, while other information, such as the knowledge and beliefs of the patients, could not be measured.  The primary measure of compliance was clinic attendance, which has the advantage of being easily measured without patient deception, but which may not be equivalent to medication use.  Assessment of compliance was rarely recorded in the clinic’s physicians’ notes, but the nurses, at the time of the first follow-up visit, were able to accurately identify patients with suboptimal compliance who were likely to drop out later.  This finding cannot be generalized because a standardized protocol for evaluation of compliance was not used, but it suggests that it is possible to identify non-compliers early in the course of therapy, thus providing an opportunity to target compliance-enhancing interventions to such patients.

Q17_Conc:
Among 352 patients, factors significantly associated with compliance with anti-tuberculosis therapy were:  shorter interval to first return visit; duration of therapy of 6-9 months; and nursing assessment of patient understanding at the initiation of therapy.

Q18_Recc:
The findings from this retrospective survey suggest that non-compliance can be detected early during therapy, and that compliance can be enhanced by good communication with better patient understanding when therapy is initiated.  Compliance can also be enhanced by closer follow-ups, and shorter durations of therapy for those with less risk of reactivation.  Better understanding of non-compliant behavior, and development of effective compliance-enhancing interventions would significantly improve the efficacy of anti-tuberculosis regimens.


Q1_Title:
Knowledge, Perceptions, and Practice of Nurses Toward HIV+/AIDS Patients Diagnosed with Tuberculosis

Q1_Author:
Messmer, P., Jones, S., Moore, J., Taggart, B., Parchment, Y., Holloman, F., & Quintero, L.

Q1_Journal:
The Journal of Continuing Education in Nursing

Q2_Key:
Knowledge and attitudes towards TB, infection control, HIV

Q3b_Both:
This research addresses knowledge and attitudes, as well as compliance with infection control standards for HIV/AIDS patients diagnosed with TB.

Q6_ReQue:
Research hypotheses as stated in article: nurses who participate in an educational program will: 
1) demonstrate a greater knowledge of AIDS and TB compared to nurses who do not participate; 
2) exhibit more positive attitudes towards patients with AIDS and TB compared to nurses who do not participate; 
3) demonstrate an increased level of compliance to infection control standards compared to nurses who do not participate

Q7_TheoBas:
King’s concept of perception from “Goal Attainment Theory”

Q8_SampCom:
55 (analysis only completed on 50 participants; 35 in experimental group, 15 in control group

Q14_Desc:
The purpose of this study was to determine if an educational program could improve nurses’ attitudes, level of knowledge, and compliance with infection control standards for HIV/AIDS patients diagnosed with TB. The experimental group (35) and control group (15) were both given a knowledge test and attitude survey. Researchers also observed participants for compliance with infection control standards. An educational program was delivered to the experimental group, consisting of a series of videos, followed by group discussion. One week after the intervention, both groups re-took the knowledge test and attitude survey, and were once again observed for compliance with infection control standards.

Q15_Outc:
Following the intervention, nurses in the experimental group demonstrated more TB knowledge than those in the control group. The experimental group also showed greater improvement in adherence to respiratory isolation and universal precaution protocols as compared to the control group. No tangible increase in knowledge of AIDS, or in the attitudes or concerns about caring for these patients was observed. Also observed was an increase in compliance for PPD testing by the experimental group, to 100%.

Q17_Conc:
This study supports the need for ongoing educational programs and continuous monitoring of infection control practices to positively affect client and provider outcomes.


Q1_Title:
Knowledge and beliefs about tuberculosis among non-working women in Ravensmead, Cape Town

Q1_Author:
Metcalf, C.A., Bradshaw. D., & Stindt, W.W.

Q2_Key:
tuberculosis; knowledge; beliefs; Cape Town; Africa

Q6_ReQue:
A study was undertaken to determine the knowledge and beliefs about tuberculosis in non-working women living in Ravensmead, Cape Town (South Africa) in order to make recommendations about future tuberculosis education priorities.

Q13_Comm:
Use of design effect of cluster sampling technique

Q14_Desc:
A community-based survey on knowledge and beliefs about tuberculosis was conducted on non-working women living in Ravensmead, Cape Town (South Africa).

Q15_Outc:
121 female respondents between the ages of 16 and 65 were interviewed.  The major results of the survey included:
1) Awareness of TB: 79% of respondents gave this disease as one of the three most prevalent illnesses in Ravensmead.
2) Symptoms of TB: Cough, loss of weight, and night sweats were identified by at least 90% of respondents.
3) Top 3 causes of TB: Cold weather, smoking and malnutrition or poor eating habits
4) Top 3 modes of transmission: Sputum, airborne, and sharing toilets, bath towels or clothes (results on this section are falsely low due to overlap with causes of TB)

All the women in the survey considered TB to be treatable and said that they would seek medical treatment if they thought that they had it.

Q16_Limt:
The results of this study are not directly comparable to other local studies that have been published since some have studied blacks and some have been on TB patients.  Comparison with other studies is further limited by differences in questions and the way in which questions were posed.

There could have been sampling bias in that 1) interviewers only interviewed the first woman who came to the door, and 2) they did not re-visit homes where no one was at home at the time of the first visit.  Also, interviewing 1 person per house limited the sample size and thus limited the stratified analysis of results.

Q17_Conc:
The women in this study showed a high level of awareness of TB, and overall knowledge about TB in this group was good, but the study revealed misconceptions about the causes and transmission of tuberculosis.  Also, there is evidence that knowledge does not follow appropriate action.  Knowledge alone is insufficient and needs to be accompanied by attitudes towards TB which promote behavior in the event of symptoms developing, TB being diagnosed, and in relating to members of the family and community who have the disease.

Q18_Recc:
In TB education an attempt should be made to dispel the misconceptions about modes of transmission expressed by some women in this study, and to reassure people that contact with people on TB treatment is safe.

The magnitude of the design effects observed in this study indicate that in surveys using cluster sampling, doubling the required sample size estimated on the assumption of simple random sampling should adequately compensate for the clustering of certain responses.

Future TB education in this group should build on existing knowledge and awareness and should aim to change attitudes and behavior.  The symptoms of TB should be publicized and symptomatic people in the community should be encouraged to present for screening by stressing the benefits of early diagnosis and treatment. 

Further research into the reasons for people with symptoms failing to present for screening would be of value in planning effective intervention strategies.  An attempt should be made to allay the fear of TB and to lessen the social stigma attached to the disease.


Q1_Title:
Tuberculosis among the foreign born in Massachusetts, 1982-1994: a reflection of social and economic disadvantage

Q1_Author:
Mitnick, C., Furin, J., Henry, C., & Ross, J.

Q6_ReQue:
What is the impact of social support (including the potential for resource assess through citizenship) on TB incidence?

Q8_SampCom:
TB cases from ’82-94 with known country of origin: 5280

Q9_Other:
Census data used in conjunction with TB incidence data

Q10_AduFrBrn:
foreign born in Massachusetts (specific group not specified)

Q10_ACIFrBrn:
foreign born in Massachusetts (specific group not specified)

Q14_Desc:
This paper examines the case of foreign born with TB and seeks to demonstrate that other factors (such as social and economic ones) contribute to the elevated levels of TB incidence in these populations.

Q15_Outc:
Results of the ecological log linear regression analysis show that the indicators of poverty, social support and access to services can further explain the elevated levels of TB incidence among foreign born populations in Massachusetts.

Q16_Limt:
While the analysis detected ecological associations in the data, the authors recognize the importance of conducting individual level analyses to verify these associations.  The limited number of observations (cases by country) make it possible that there is “estimate instability.” The lack of individual level data makes it questionable to assume that everyone from a certain country living in poverty is at the same level of risk. This study design was not able to distinguish any temporal sequencing (for example, is poverty instrumental in causing higher TB incidence, or does TB diagnosis lead to economic and social disadvantage?).

Q17_Conc:
Certain conditions amenable to social and economic intervention may help explain the increased TB rates among foreign born in the US.  Social and economic factors on an individual level should be assessed through the screening and intervention. While country of origin is an important predictor of population incidence rates of TB, indicators of poverty and social support, and resource access also predict variability in country-specific incidence rates.

Q18_Recc:
A matched case control study should be designed to measure the impact of economic and social disadvantage among the foreign born on TB incidence, matching for factors such as age and infection status on arrival.


Q1_Title:
Compliance with Antituberculosis Regimens and the Role of Behavioral Interventions

Q1_Journal:
Handbook of Health Behavior Research II: Provider Determinants

Q3b_Both:
This chapter discusses behavioral issues that relate to TB control and includes internal and external influences on behavior.

Q14_Desc:
This chapter outlines the major areas of concern in the management and control of TB, and the role of behavioral interventions, particularly with relation to TB treatment completion.

Q15_Outc:
Studies in TB control reveal several methodological issues that should be addressed. These include: a tendency for those researching compliance to focus their examination on the patient; difficulties in comparing studies that use different measures of compliance; and selection bias seen in many studies (the patient population being studied is often not representative of all individuals with active TB.

Q18_Recc:
Research questions to address highlighted methodological issues include: 1) how might differences between those who seek treatment and those who do not, later influence compliance behaviors? 2) Are individuals with symptom the only ones who seek care? 3) If so, in what ways are individuals who have symptoms but do not seek care different? 

A systems approach in TB treatment and control programs should contain a medical component as well as a referral component that directs patients to agencies addressing housing, entitlements, public assistance, and substance abuse.


Q1_Title:
Behavioral Interventions for the Control of Tuberculosis Among Adolescents

Q1_Author:
Morisky, D., Malotte, C., Ebin, V., Davidson, P., Cabrera, D., Trout, P., & Coly, A.

Q3b_Both:
The article focused on educational strategies to improve medication adherence among adolescents.

Q6_ReQue:
To develop and test the effects of educational innovative strategies on infected adolescents at two health centers serving ethnically diverse populations.

Q14_Desc:
The authors used a randomized experimental four-group design to assess the independent and combined effects of peer counseling and a participant-parent contingency contract intervention.  The four arms of the study included: 1) peer counseling intervention; 2) parent-participant contingency contract intervention; 3) combined intervention of arms 1 and 2; and 4) usual care.

Q15_Outc:
Participants randomized to the peer counseling groups demonstrated significantly greater improvements in self-efficacy and mastery than the usual care group.  Self-efficacy for medication-taking behavior at post-test correlated strongly with completion of care.  The results also indicate that parental support in medication-taking can positively influence adolescent adherence.

Continuing education seminars and workshops were implemented for TB control staff at the two health clinics and for all TB Control Division staff at the Los Angeles County Health Department.  Educational materials and a training manual for enhancing completion of treatment for LTBI through tailored educational approaches were developed and disseminated to the clinics.

Q16_Limt:
The participation in the interviews and the monetary incentives provided to the participants may have heightened their awareness of their treatment.  Another limitation related to the contingency contracts was the lack of assurance that the adolescents in the study actually received the incentives their parents agreed to provide.  Also, several Spanish-speaking participants had difficulty understanding the response scales, which ranged from strongly agree to strongly disagree in English.  There were no exact equivalents in Spanish.  As a result, the validity of those data may have been compromised.

Q17_Conc:
Health education and incentives are helpful adjuncts to the completion of treatment for LTBI in adolescents.

Q18_Recc:
Clinicians should consider incorporating peer counseling and a participant-parent contingency contract into the usual care procedures of TB control for adolescents.


Q1_Title:
A Patient Education Program to Improve Adherence Rates with Antituberculosis Drug Regimens

Q1_Author:
Morisky, D., Malotte, C., Choi, P., Davidson, P., Rigler, S., Sugland, B., & Langer, M.

Q2_Key:
TB; patient education; adherence; drug regimens

Q3b_Both:
This article describes an intervention that focuses on increasing patient adherence to treatment by providing several incentives, such as health education counseling and a monetary incentive.

Q6_ReQue:
What are the effects of an innovative health education approach to improving adherence rates among active and chemoprophylactic patients with TB?

Q7_TheoBas:
Health Belief Model; Planning Framework - PRECEDE

Q8_SampCom:
205 (n=88 patients with active TB; n=117 preventive patients with no evidence of TB)

Q14_Desc:
Participants were randomly assigned to special intervention or usual care groups.  A 50-question interview was conducted on both usual care groups (active and preventive).  Usual care active patients received standard clinic treatment, follow-up phone calls or home visits by clinic personnel if the patient missed an appointment.  Usual care preventive patients were supposed to receive a new appointment sent on a postcard by clinic staff if patient missed appointment.  Special intervention subjects received the usual care group treatment plus health education counseling and an incentive at each monthly interview following baseline.  Counseling sessions included tailored educational messages and a TB information booklet.

Q15_Outc:
There were no statistically significant differences found between the two groups.  Results indicate that active cases were more likely to keep their appointments than were preventive cases.  More special intervention active cases took 95% or more of their meds versus the usual care active cases.  There was three times the number of special intervention patients versus usual care patients who remained in care.

Q16_Limt:
It is hard to determine which intervention component contributed to the differences found between the special intervention and usual care groups because it was delivered as a package.

Q17_Conc:
Results demonstrate the positive effects of a structured health education program on the improvement of continuity of care and adherence behavior among patients with TB.

Q18_Recc:
Results suggest that attention should be focused both on enhancing the provider-patient interaction and identifying an appropriate incentive scheme which would appeal to the individual.  Better follow-up methods are needed for missed appointments.  Patient educational activities should be formally integrated into the patient-care process.  Additional research is needed to investigate the independent and combined effect of incentives in enhancing patient-adherence to medical recommendations.


Q1_Title:
HIV-infected adolescent and adult perceptions of tuberculosis testing, knowledge and medication adherence in the USA

Q1_Author:
Murphy, D., Rotheram-Borus, M., & Joshi, V.

Q2_Key:
HIV; adolescents; adults; perceptions; TB; knowledge; compliance; USA

Q6_ReQue:
What are the perceptions of TB infection rates, physician TB behavior, and patient knowledge of TB transmission and treatment adherence among HIV-infected adolescents and adults?

Q11_USA:
California & New York:  Los Angeles, CA; San Francisco, CA; New York City, NY

Q12_Oth:
New York City Human Resources Administration’s Division of AIDS Services

Q14_Desc:
HIV-infected adolescent and adult perceptions of TB infection rates and physicians’ TB behavior, and patient knowledge of TB transmission and treatment adherence were assessed.  A brief TB questionnaire was administered to all participants as part of a larger assessment conducted for enrollment in a psychosocial intervention study.  Questions were asked regarding: a) subjects’ perceptions of whether their physician had ever discussed TB; b) subjects’ perceptions of whether they had ever been tested for TB; c) TB knowledge in general; d) availability of resources and the importance of physician-patient interaction.  Patients who previously or currently had active TB were asked if they had completed their medication course.

Medical chart abstraction was conducted for the adolescent sample.  Some of the medical abstraction questions matched the questions the participants were asked in their interview.

Q15_Outc:
Adolescents reported they were significantly less likely to be tested, although testing rates were high for both samples.  Approximately 9% of both samples reported infection with TB; the majority of whom reported receiving medication (97%), and consistent medication adherence (93%).  The overall mean knowledge score was 66%, with adolescents being less knowledgeable than adults, and young males being less knowledgeable than young females.  Age, gender, and experience with TB significantly predicted accuracy of knowledge about TB.

Q16_Limt:
The majority of the data in this study is based on self-report.

Q17_Conc:
Results indicate that if HIV-infected individuals, a population at very high risk and often among the least able to afford health care resources, receive the education and support they need from their community health care sources they may substantially reduce their chances of contracting and spreading TB.


Q1_Title:
Social, economic and operational Research on Tuberculosis:  Recent Studies and some Priority Questions

Q2_Key:
Social, economic, short course chemotherapy, Malawi, Mozambique, Tanzania, cost-effectiveness, hospitalization

Q6_ReQue:
Objective:  To examine the costs and effectiveness of the national tuberculosis programs in Malawi, Mozambique, and Tanzania.

Q12_Oth:
TB control programs in Malawi, Mozambique, and Tanzania

Q14_Desc:
This paper traces the contribution of recent social, economic, and operational research to this resurgence and the role that such work may play in supporting the fight against tuberculosis in the future.  The paper is divided into two parts:  studies on the burden of tuberculosis and studies on the cost-effectiveness of interventions against tuberculosis in developing countries.  (The sub-topics covered include:  the burden of tuberculosis, incidence and mortality of tuberculosis, age-distribution of tuberculosis, tuberculosis in young women, priorities for further research on the burden of tuberculosis, cost-effectiveness of chemotherapy for tuberculosis, benefits, standard and short-course chemotherapy, and hospitalization versus completely ambulatory therapy.

Q15_Outc:
Benefits:  The benefits of chemotherapy for smear positive tuberculosis can logically be divided into two types:  direct benefits to the patient treated and indirect benefits to others through reduced transmission of tuberculosis.  In Malawi, Mozambique, and Tanzania, short-course chemotherapy is cheaper than standard chemotherapy per death averted and year of life saved for both hospital and ambulatory chemotherapy.  In reality, the cost per unit benefit is extremely close for the two regimens even if somewhat cheaper for short-course chemotherapy.  The author concludes, however, that short-course chemotherapy is preferable in virtually all cases for a number of reasons.  In economic terms, the margin for purchasing these benefits at the given price is deeper for sort-course chemotherapy.  More cases can be cured at this low price using short-course chemotherapy because the cure rate is higher. If for the same price per death averted, one can help more people, then clearly the invention that can help more people is preferable.

Hospitalization versus completely ambulatory therapy:  The unit costs and cost-effectiveness rations provided illustrate that feasible ambulatory chemotherapy is much cheaper than hospital chemotherapy.  The key question, however, remains:  when is it worth the extra resources of hospital based chemotherapy in order to increase the cure rate?  Using the marginal increase in cost to hospitalize a patient for Malawi, Mozambique, and Tanzania, the author shows that if hospitalization increases compliance by only 5%, it will cost US $777-2,008 per case cured.  If it increases compliance by 10%, it will cost $389-10,004.  If hospitalization increases the cure rate by 15%, the marginal cost per case cured is not much different than the average incremental cost of curing a case with any form of chemotherapy--$259-669.  A twenty-percentage point increase in the cure rate would cost $194-502.

Q17_Conc:
Chemotherapy for smear-positive tuberculosis is found to be among the most cost-effective health interventions known, costing 1-4 US dollars per year of life staved.  In all situations, short-course chemotherapy is found to be more cost-effective than standard 12-month chemotherapy.  General conclusions about the role of hospitalization are difficult to make; its cost-effectiveness depends on local patterns of compliance and the cost of hospitalization.

Q18_Recc:
Priorities for further research on the burden of tuberculosis:  The analysis of the incidence, mortality, and age-distribution of tuberculosis needs to be performed at the national level using existing data sources in many countries. Such work is essential to persuade governments and local public health leaders that tuberculosis in their own countries continues to be one of the top public health priorities.  Experience is showing that global or even regional estimates of the tuberculosis problem are not persuasive enough to convince many governments that tuberculosis is one of their outstanding public health problems.


Q1_Title:
Wasted Lives:  Tuberculosis and Other Health Risks of Being Haitian in a U.S. Detention Camp

Q3b_Both:
Describes Haitian culture (internal) in an immigrant detention camp (external).

Q6_ReQue:
This article explores attitudes of Haitian men towards TB diagnosis and chemotherapy.

Q14_Desc:
An ethnographic account of the experiences of TB positive Haitian men detained at an INS camp outside of Miami. The article describes life in Krome, and discusses the beliefs and culture of the men and how these factors influenced their environment and time in the detention camp.

Q15_Outc:
Themes emerging from this research include: dehumanizing character of the camp, receipt of medication was degrading, resignation, and insistence of detainees as unique individuals. The author provides reactions to diagnosis and treatment of TB for both patients and non-patients at the camp.

Q17_Conc:
Traditional Haitian beliefs about health and illness contrast in many ways with those held by practitioners of biomedicine.


Q1_Title:
Tuberculosis in Bombay: new insights from poor urban patients

Q2_Key:
TB, poor, urban, health seeking behavior

Q6_ReQue:
The purpose of this study is to explore the health seeking behavior of poor TB patients in Bombay, to understand their perceptions of the cause of disease, and to examine the effects of TB on their personal lives.

Q14_Desc:
An opportunistic sample of 16 patients was drawn from the 120 TB patients who attended PATH’s TB clinic.  Study was limited to adults because of the focus on gender differentiated experience of adult TB patients.  Initially, 4 married and one single man, and three married and two single women were interviewed.  In addition, 2 more of each single and married women and 2 more single men were interviewed.  Based on this sample, health seeking behaviors, perceptions of the cause of disease, and the effects of TB on their personal lives was analyzed

Q15_Outc:
Results fell under 3 main categories: knowledge, health seeking behavior and effects on personal lives.  Almost equal numbers of respondents stated ‘germs’ and ‘worry’ as the cause of TB.  Men worried about losing wages, financial difficulties, reduced capacity for work, poor job performance and the consequences of long absences form work.  Women were concerned about rejection by husband, harassment by in-laws, and the reduced chances of marriage (for single women), in addition to their concerns about dismissal from work.  In the first two months patients took home remedies.  When symptoms persisted, private practitioners were contacted; they were usually unable to correctly diagnose disease.  Respondents they shifted to NGOs for affordable and better quality treatment.

Q16_Limt:
The sample of this study is small and non-representative; it also has selection bias as not all who were approached consented to be interviewed.  Hence, definitive conclusions about the effect of TB on the lives of men and women in urban areas can not be drawn.  These findings have definitive implications in two areas concerning TB control: the delivery of TB services by private and public sectors and outreach to women patients suffering form TB.

Q17_Conc:
Health programs will have to be sensitive to the different needs and concerns of urban men and women with TB; in the case of women, health care providers will have to make particular efforts to identify and treat married women with TB completely.

Q18_Recc:
The distinct experiences of married and unmarried women needs further examination.  Need more studies which capture gender-disaggregated lay concerns with the interface between the physical and mental tensions of city life, and its manifestation as health problems.


Q1_Title:
Short-Course Rifamycin and Pyrazinamide Treatment for Latent Tuberculosis Infection in Patients with HIV Infection

Q1_Author:
Narita, M., Kellman, M., Franchini, D., McMillan, M., Hollender, E., & Ashkin, D.

Q2_Key:
HIV, TB, isoniazid, rifabutin, rifampin, dot, LBTI

Q6_ReQue:
To determine the completion rate and tolerability of short-course rifamycin and pyrazinamide treatment of LTBI in HIV-infected patient through a comprehensive community based program.

Q8_SampCom:
3118 screened for LTBI; 135 LTBI  in drug group; 93 LTBI historical controls (INH)

Q10_AduFrBrn:
Haitian, Jamaican, Venezuelan, Cuban, Columbian, and additional not stated

Q13_Comm:
p < .05; Chi-square, Fisher’s Exact tests (categorical variables); t-test (continuous, normal variables); Rank sum test (continuous, non-parametric)

Q14_Desc:
This study was undertaken to evaluate the completion rate and tolerability of the short-course, twice weekly rifamycin/pyrazinamide regimen in a community setting.  We describe our experience in a prospective cohort of HIV-infected patients with LTBI, utilizing this regimen in Broward County, Florida.

Q15_Outc:
Of 135 patients receiving rifamycin/pyrazinamide, 124 patients (92%) completed treatment; 5 patients had to discontinue treatment due to side effects (allergic skin reactions [n = 4], hepatitis [n = 1].  The completion rate of the historical control group who received INH therapy was 61% (57 of 93 patients; p < 0.001); none of those who received INH experienced significant side effects.

Q16_Limt:
There are several limitations to our study.  First, the treatment of LTBI was not randomized; thus there may have been bias in that physicians prejudged whether individuals would be nonadherent with the LTBI treatment and those deemed nonadherent were assigned to self administered INH therapy in order to minimize potentially wasted effort in providing DOT.

Q17_Conc:
In our experience, a comprehensive, community based program of rifamycin/pyrazinamide for LTBI achieved significantly higher adherence that that of traditional INH therapy, and thus may provide improved TB prevention in a community with high prevalence of HIV-infected patients.


Q1_Title:
Socio-economic, gender and health services factors affecting diagnostic delay for tuberculosis patients in urban Zambia

Q1_Author:
Needham, D., Foster, S., Tomlinson, G., & Godfrey-Faussett, P.

Q2_Key:
socio-economic; gender; health services; TB; Zambia; diagnostic delay; Africa

Q3b_Both:
This article focuses on assessing the effect of several factors, such as socio-economic status, gender, and the health services system, on diagnostic delay for tuberculosis.

Q6_ReQue:
What are the effects of socio-economic status, gender, health-seeking behaviors, and health services system on diagnostic delay for tuberculosis?

Q14_Desc:
The purpose of this study was to clarify the factors, such as socio-economic characteristics, gender, health-seeking behaviors, and health services systems, which are associated with patients’ diagnostic delay for tuberculosis within a typical urban African setting.

Q15_Outc:
The mean diagnostic delay was 8.6 (9) weeks, and was significantly associated with the following factors: female sex, lower education, more than six instances of health-seeking encounters, outpatient diagnosis of TB, and visiting a private doctor or traditional healer.

Q17_Conc:
More effective TB control interventions require novel methods of accessing women and less educated people.  Decentralization of public tuberculosis care and improved integration with private sector health providers may also reduce diagnostic delay.

Q18_Recc:
Refer to conclusions; education regarding the symptoms and signs of TB directed at these health providers may enhance case-finding and minimize diagnostic delay.  Better integration of the private sector into the public sector TB control program may also help.  Expanded communication skills training for local public health service may also improve patient satisfaction with public-sector services.


Q1_Title:
Barriers to tuberculosis control in urban Zambia:  the economic impact and burden on patients prior to diagnosis

Q1_Author:
Needham, D., Godfrey-Faussett, P., & Foster, S.

Q2_Key:
Costs, diagnosis, care-seeking patients, Africa, care-giver

Q6_ReQue:
Objective:  To study the pre-diagnosis economic impact, burden, and barriers to care seeking for tuberculosis patients in urban Zambia.

Q13_Comm:
For the purposes of their work, the authors identified statistical significance at P<0.05.

Q14_Desc:
Through study of the pre-diagnosis patient-related costs of TB at University Teaching Hospital in Lusaka, the present research was aimed at estimating the economic impact and burden of TB on patients, and the assessment of whether this burden may present potential barriers to TB control in similar settings in sub-Saharan Africa.  (A principal investigator conducted in-depth interviews over a 9-week period with adult in-patients and outpatients registering with new pulmonary tuberculosis.)

Q15_Outc:
202 patients completed interviews:  64% normally worked, but 31% stopped due to their tuberculosis, with an average of 48 days off.  The mean duration of illness prior to their tuberculosis registration was 63 days, with 64% of patients delaying in presenting to the Chest Clinic.  Of these, 38% blamed money shortages for their delay.  In seeking diagnosis, patients incurred a mean total cost equivalent to 127% of their mean monthly income; direct expenditures represented 60% of this cost.  In addition, patients lost, on average, 18 workdays prior to diagnosis.  Caregivers incurred costs equivalent to 31% of the mean monthly income.  (Non-medical expenditures represented 55% MMI.  Patients’ mean transportation spending represented over one quarter of this burden, although for those families who incurred the cost, transportation was greater for care-rivers than patients.)

Q16_Limt:
A limitation of the study is that patients who were unable to seek care at the Chest Clinic were excluded.  Patients may have died of tuberculosis either at home or in hospitals before registering at the Chest Clinic, possibly due to economic barriers delaying their diagnosis.  This may serve to underestimate the economic burden of tuberculosis on patients.

Q17_Conc:
The resulting economic burden on patients and caregivers is an important contributing factor to delayed diagnosis and continued disease transmission.  Important economic barriers include lost income, transportation expenditures, and spending on special food.  Reducing these barriers by decreasing the number of health encounters and travel distances and, as a consequence, minimizing the duration of illness before diagnosis, is a key consideration for health planners in designing an effective tuberculosis control program.

Q18_Recc:
A majority of patients did not have scheme [medical insurance] coverage.  Although medical care for tuberculosis is free, scheme coverage (or payment of a more expensive consultation fee) is required for outpatient consultation and referral to the Chest Clinic.  This is often the first barrier that tuberculosis patients encounter while seeking care within the public sector health system.  Recommendation:  structural efforts to increase scheme coverage in Zambia.


Q1_Title:
High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand

Q1_Author:
Ngamvithayapong, J., Winkvist, A., & Diwan, V.

Q2_Key:
TB, HIV/AIDS, beliefs, perceptions, stigma, delay seeking care

Q6_ReQue:
The aim of this study was to elicit community perceptions about TB and the behavior of TB patients in an area where significant public health attention has been focused on AIDS.

Q14_Desc:
From May to June 1998 a team of a moderator, a note taker and a support staff conducted 11 focus group discussions (FGD) (6 male, 5 female).  As information on the public’s perception of TB is lacking in Chiang Rai, Thailand, we used FGD as a data collection method to explore people’s perspectives on TB.

Q15_Outc:
People had good knowledge of AIDS but they knew little about TB.  Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB immediately and sought medical care.  Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, food and drinks, and closeness to TB patients.

Q17_Conc:
In a high endemic HIV/AIDS situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

Q18_Recc:
We need well-designed studies of both micro and macro level of disease control.


Q1_Title:
Attitudes toward Tuberculosis in Vietnamese Immigrants

Q1_Author:
Nguyen, L., Yamada, S., Matsunaga, D., & Caballero, J.

Q1_Journal:
Asian American and Pacific Islander Journal of Health

Q6_ReQue:
To explore Vietnamese immigrants’ knowledge, attitudes, beliefs, and practices concerning tuberculosis.

Q14_Desc:
The purpose of this study was to acquire an understanding of the Vietnamese cultural beliefs and conceptions about TB.  There were 3 focus groups consisting of Vietnamese participants recruited from the patient populations of 3 community health centers in California.  The participants were foreign-born, immigrant, economically disadvantaged, and with limited English skills.  They were asked 11 open-ended questions regarding beliefs about the causes of TB, reasons for susceptibility to the disease, its symptoms and its mechanism, prognosis, treatment and its social consequences.

Q15_Outc:
The focus group participants attributed TB to malnutrition, stress, smoking, alcohol consumption, and hard labor.  They expressed a belief in the extreme contagiousness of TB, that it can be spread through eating utensils or towels.  Lung diseases and other organ complications were cited to be the chief problems of TB.  The participants expressed belief that the use of Western medicine is more effective in treating TB than other forms of treatment such as acupuncture or herbal medicines.  A consequence of the extreme contagiousness of TB is social isolation, leading to mental anguish.

Q16_Limt:
One limitation was the small sample size and that the individuals were not randomly selected, so the study findings cannot be generalized to Vietnamese elsewhere.  Another limitation was that differing opinions among focus group members could not be incorporated.  The researchers also could not control the extent to which the participants were exposed to TB education.  Therefore, the responses in this study do not indicate that Vietnamese are more knowledgeable about TB than other groups.

Q17_Conc:
An understanding of shared attitudes toward TB in Vietnamese may contribute to the treatment of patients with TB.  Community education to rectify some common misconceptions may be of utility.

Q18_Recc:
The lack of knowledge and misconceptions about TB as presented in this study points to the need for more TB education, especially on the route of transmission, the prognosis, and the rationale for treatment.  Practitioners, including community health care workers, who provide health care for Vietnamese immigrants need to have an awareness about the common cultural attitudes held by Vietnamese in order to enhance the effectiveness of the clinical encounter.


Q1_Title:
Illness Semantics and International Health: The Weak Lungs/TB Complex in the Philippines

Q2_Key:
illness semantics, TB pharmaceuticals, Philippines

Q6_ReQue:
The ethnographic study considers the weak lungs/TB complex as it is conceptualized in relation to other types of lung disease as well as predisposing factors which influence the moral identity of the afflicted and the social relations of illness.

Q8_SampCom:
[135= 50 lower class literate mothers completed open-ended interview + 20 mothers were  attribute recognition informants + 65 focus group ppts (13 f.g. x 5 ppts each, such as community people, government midwives, men, former weak lungs/TB patients)

Q10_AduOth:
mothers, men, government midwives and other residents of a rural coastal area of central Oriental Mindoro in the Philippines

Q11_Intl:
Philippines:  rural coastal area of central Oriental Mindoro

Q14_Desc:
A four-month ethnographic study of TB-related behavior was conducted on an island of the Philippines. Interviews and focus groups were conducted to document the weak lungs illness category and how weak lungs has influenced perceptions & usage of TB medications by community people and health care providers.

Q15_Outc:
The illness category “weak lungs” is broad and covers a variety of symptom states inclusive of TB.  TB is recognized to be contagious, but many people do not consider weak lungs to be contagious. Use of the term weak lungs has important public health consequences related to perceived contagiousness, stigma, self-treatment and health care seeking behavior. 15 key findings were identified.

Q17_Conc:
The semantics of TB has important public health significance.  Weak lungs/TB is linked to a complex of illnesses in Oriental Mindoro, Philippines, which encompass acute respiratory infections, TB, and possibly lung cancer.  Broad usage of the term weak lungs affects self-treatment practices and over-the-counter purchases of TB medication.  Popular understanding of weak lungs has influenced perceptions of the purpose of TB medications leading to drug misuse, which in turn contributes to drug resistance and has important international public health ramifications.

Q18_Recc:
Studies of illness semantics, as in the case of weak lungs/TB are important to international health.


