[Multidrug-resistant tuberculosis: challenges of a global emergence]. / La tuberculose à bacilles multi-résistants: défis d'une émergence globale.

Drug-resistant tuberculosis, in particular Multi-Drug Resistant (MDR-TB) is an increasing global concern and a major burden for some developing countries, especially the BRICS. It is assumed that every year roughly 350 000 new MDR-TB cases occur in the world, on average in 20.5% of TB patients that have been previously treated but also in 3.5% of persons that have never been on TB treatment before. The global distribution of cases is very heterogeneous and is now better understood thanks to a growing number of specific surveys and routine surveillance systems: incidence is much higher in southern Africa and in all countries formerly part of the USSR. Countries with weak health systems and previously inefficient TB control programs are highly vulnerable to MDR epidemics because program failures do help creating, maintaining and spreading resistances. Global response is slowly rolled out and diagnosis capacities are on the rise (mostly with genotypic methods) but adequate and successful treatment and care is still limited to a minority of global cases. From a public health perspective the MDR-TB growing epidemics will not be controlled merely by the introduction of few new antibiotics because it is also linked to patient's compliance and adequate case management supported by efficient TB program. In depth quality improvement will only be achieved after previous errors are thoroughly analyzed and boldly corrected.

[Do health workers practice what they preach? A study of knowledge, opinions and practices of health care professionals, with respect to their own health, in Madagascar]. / Les agents de santé mettent-ils en pratique ce qu'ils enseignent? Etude sur les connaissances, les opinions et les pratiques concernant leur propre santé auprès de professionels de la santé à Madagascar.

In this study, a questionnaire was used to study the individual behavior of a sample of fifty health workers, doctors and nurses from Tamatave (Madagascar) with respect to a number of current health issues. We used the results to assess the impact and efficacy of previous training and to obtain information about the extent to which health staff actually follow the recommendations and standards that they are given and expected to teach, as far as their own health is concerned. It was clear that the standard management procedures and instructions concerning basic health-preserving behavior were far from being universally accepted and followed by health workers themselves. This was the case even for common diseases and health issues for which specific training had been given, such as malaria, diarrhea, AIDS and STDs, tobacco use, HBP management and the use of antibiotics. More attention should be paid to involving health workers in their training programs so that they are really convinced by the recommendations given. So long as most health workers are not themselves committed to the recommendations and have inadequate behavior regarding their own health, they are unlikely to be effective at promoting good health practice.

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

SETTING: Patient compliance remains one of the main obstacles that need to be overcome by tuberculosis control programmes, in the developing world as well as in industrialised countries. A better understanding of the various factors accounting for treatment default could help to achieve better compliance from patients. OBJECTIVES: To increase the understanding of the determining factors of default in an urban environment where medical facilities are accessible. Different kinds of determinants were studied: objective socio-demographic factors, subjective psychological factors, attitudes and behaviour of patients in relation to chemotherapy, quality of relationships with the medical staff, knowledge and attitudes regarding tuberculosis. DESIGN: Risk factors for default were assessed by a retrospective case-control study in a sample of 38 patients who had not completed treatment for pulmonary tuberculosis, compared with 111 controls who had completed treatment under comparable conditions. RESULTS: Default appears to be significantly linked to transportation time, the sex of the patient, patient information and the quality of communication between patients and health workers. False addresses given by patients are both a methodological bias and a risk factor for future default. CONCLUSION: Improved communication skills and attention from the medical staff could encourage more patients to complete their TB treatment.

[Evaluation of a supervision program of health centers at the district level in Madagascar]. / Evaluation d'un programme de supervision des centres de santé au niveau du district à Madagascar.

Poor supervision and follow-up have long been recognized as major weaknesses in the development of primary health care in many countries. A program has therefore been specifically developed to strengthen the supervision activities of 18 rural health centers in Madagascar. District health officers were appropriately trained and then conducted two-monthly supervision visits. The emphasis of the training program was on problem solving, program integration and on-site training. The effects of the supervision program was assessed quantitatively and objectively. Various activities of each health center were scored before intervention, and one year after implementation of the supervision program. The improvement in most health centers was substantial, both in quantitative coverage and qualitative practice. Nevertheless, some centers appear to have been resistant to change.

[Tuberculosis and patient compliance: proposition for a study methodology of patient dropouts]. / Tuberculose et adhésion au traitement: proposition d'une méthodologie d'étude de l'abandon du traitement.

Patient dropouts are one of the main concerns of tuberculosis programme in high prevalence countries. Perception of renunciation factors are generally weak or/and feeble from the part of agents working within programmes, while there are some a priori and confusions. This work proposes the setting up of a malagasy study, after the adequate definition of some hypothesis, then the writing of a survey form. The aim is to draw remedial behaviours and to make physicians and paramedical working close to tubercular patients, aware of the importance of a good mutual comprehension.