Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study.

BACKGROUND: Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services. METHODS: We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains. RESULTS: Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care. CONCLUSIONS: Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers.

BACKGROUND: Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal. METHODS: Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti. RESULTS: Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma. CONCLUSIONS: Barriers embedded in health services and care seekers' characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

Statistics and Colonial Medicine: A Doubt and Controversy on Tuberculosis Statistics in Colonial Korea.

This paper focuses on the criticism of tuberculosis statistics published by the Japanese Government-general in colonial Korea and a research on the reality of tuberculosis prevalence by medical doctors from the Department of Hygiene and Preventive Medicine at Keijo Imperial University (DHPMK). Recent studies have shown that colonial statistics shape the image of colonial subjects and justify the control to them. Following this perspective, this paper explores the process of producing the statistical knowledge of tuberculosis by medical scientists from DHPMK. Their goal was to find out the resistance to tuberculosis as biological characteristics of Korean race/ethnicity. In order to do so, they demonstrated the existence of errors in tuberculosis statistics by the Korean colonial government and devised a statistical method to correct them based on the conviction that the Western modern medicine was superior than Korean traditional medicine as well as the racist bias against Korean. By analyzing how the statistical concepts reflected these prejudices, this paper argues that the statistical knowledge of tuberculosis created images that Japanese people was healthier and stronger than the Korean people and justified the colonial government's control over Korean.

Explaining patient delay in healthcare seeking and loss to diagnostic follow-up among patients with presumptive tuberculosis in Tanzania: a mixed-methods study.

BACKGROUND: Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania. METHODS: In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU. RESULTS: Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08-7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16-0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98-2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62-8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01-2.17). CONCLUSION: Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women's health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.

Does being on TB treatment predict a higher burden of problems and concerns among HIV outpatients in Kenya? a cross-sectional self-report study.

Tuberculosis illness is associated with uncertain outcomes, and has high prevalence among people living with HIV. The new World Health Organization's End TB strategy specifies person-centred symptom management and psychosocial support alongside treatment within its pillars and components. There is a paucity of research to inform an effective care response in Kenya in terms of self-reported outcomes. We aimed to measure the three day period intensity of problems and concerns (physical, psychological, social and spiritual), and identify predictors of problems and concerns, among HIV patients attending outpatient care. We conducted a cross-sectional self-report quantitative study among adult (aged at least 18 years) patients with confirmed HIV diagnosis, and aware of their diagnosis and attending HIV outpatient care in Kenya. Multi-dimensional palliative care problems and concerns were collected using African Palliative Outcome Scale (APOS). Ordinal logistic regression assessed the association of multi-dimensional problems and concerns controlling for demographic variables (age, gender, education and wealth) and clinical variables (WHO clinical stage, HIV treatment status, TB treatment status, and CD4 count). We recruited N = 400 participants. N = 61 (15.64%) were on TB treatment. The items with worst score responses were help and advice to plan for the future (52.5%), ability to share feelings (46.25%), at peace (30.75%) pain (27%) and life worthwhile (18.75%). TB treatment status was associated with lower (worse) score for APOS total score (odds ratio .59, 95% CI .36 to .99; P = 0.046) and factor 3(existential and spiritual wellbeing: .55, .32 to .92; p = 0.023). Interestingly higher CD4 count was predictive of lower (worse) factor 3 outcomes (existential and spiritual wellbeing: .84, 95% CI 73 to .97; p = 0.014). This study informs the new WHO End TB policy with novel data on specific clinical needs. This calls for holistic symptom assessment, person-centred care and holistic management to respond positively to the End TB strategy.

Meanings of 'Tuberculosis' in Rural Indigenous Communities from a Municipality in the Colombian Amazon.

OBJECTIVES: The purpose herein was to describe the meanings on tuberculosis (TB) in rural indigenous communities from a municipality in the Colombian Amazon. METHODS: This was an ethnographic study with theoretical reference of dialectical hermeneutics, which created focus groups, one for each rural community of Puerto Nariño, for a total of 15 focus groups. The participants were community leaders and health referents. RESULTS: Seventy-nine subjects participated, mostly midwives, kurakas, traditional physicians, and shamans. The analysis yielded four categories: knowledge of TB, attitudes regarding TB, community practices of TB, and the intervention proposal on TB by the participants. It was found that community leaders recognize TB as a disease that can cause death, but which can be cured if timely care is secured. The study also identified the need to conjugate western medicine with traditional medicine. CONCLUSIONS: It is recognized that meanings may impact upon knowledge, attitudes, and practices that affect early detection and treatment of the disease. In addition, this work corroborates the need to strengthen and develop educational programs on tuberculosis supported by the real needs of the communities to enhance their knowledge, attitudes, and practices on the disease.

Improving knowledge and behaviours related to the cause, transmission and prevention of Tuberculosis and early case detection: a descriptive study of community led Tuberculosis program in Flores, Indonesia.

BACKGROUND: The community's awareness of Tuberculosis (TB) and delays in health care seeking remain important issues in Indonesia despite the extensive efforts of community-based TB programs delivered by a non-government organisation (NGO). This study explored the knowledge and behaviours in relation to TB and early diagnosis before and after an asset-based intervention designed to improve these issues. METHODS: Six villages in Flores, Indonesia were purposively selected to participate in this study. Three villages served as intervention villages and the other three villages provided a comparison group. Data collection included interviews, group discussions, observations, field notes and audit of records. RESULTS: In total, 50 participants across six villages were interviewed and three group discussions were conducted in the intervention villages supplemented by 1 - 5 h of observation during monthly visits. Overall, participants in all villages had limited knowledge regarding the cause and transmission of TB before the intervention. The delay in health seeking behaviour was mainly influenced by ignorance of TB symptoms. Health care providers also contributed to delayed diagnosis by ignoring the symptoms of TB suspects at the first visit and failing to examine TB suspects with sputum tests. Stigmatisation of TB patients by the community was reported, although this did not seem to be common. Early case detection was less than 50 % in four of the six villages before the asset-based intervention. Knowledge of TB improved after the intervention in the intervention villages alongside improved education activities. Early case detection also increased in the intervention villages following this intervention. The behaviour changes related to prevention of TB were also obvious in the intervention villages but not the comparison group. CONCLUSION: This small project demonstrated that an asset-based intervention can result in positive changes in community's knowledge and behaviour in relation to TB and early case detection. A continuing education process is like to be required to maintain this outcome and to reach a wider community. Promoting community involvement and local initiatives and engaging health care providers were important elements in the community-based TB program implemented.

Harnessing Photovoice for tuberculosis advocacy in Karachi, Pakistan.

In Pakistan, despite publically available free testing and treatment throughout the country, there were an estimated 58,000 deaths due to tuberculosis in 2010. Understanding the experiences of people affected by TB is essential in addressing barriers to effective treatment. The Indus Hospital used Photovoice to understand the experiences of people affected by TB in Karachi. Two hundred and thirty photographs and stories were collected from 55 people affected by TB. Five major themes and 12 sub-themes emerged from the data: the physical aspects of TB (weakness and the side effects of the medication), the social aspects of TB (loneliness, stigma, and the fear/guilt of infecting family members), the socio-economic aspects of TB (financial difficulties/poverty and poor living conditions), supportive factors during treatment (support from family and friends, support from welfare organizations, prayer, visiting peaceful places), and recovery (happiness about getting better). The photographs, stories, and a Call for Action were shared at a Gallery event with patients, practitioners, and policy-makers. This study provides a look at the complexities surrounding TB and emphasizes the need for holistic interventions for TB that address all aspects of the disease, including its social determinants. It also highlights the potential of Photovoice as an effective means to bring much-needed attention to this disease.

Health care workers' knowledge and attitude towards TB patients under Direct Observation of Treatment in Plateau state Nigeria, 2011.

INTRODUCTION: Tuberculosis (TB) is a public health problem in Nigeria. Adherence to the total duration of treatment is critical to cure the patients. We explored the knowledge of the health care workers on management of TB patients including their perceived reasons for patient non adherence to treatment to develop strategies to improve the quality of the TB control service in the state. METHODS: We conducted a cross sectional study. We used self administered questionnaire to extract information from the health workers on their trainings for TB control, knowledge of the control services, patients' education including prevention of defaulting from treatment. We conducted focus group discussion with the health care workers. We performed descriptive analysis using epiInfo software. RESULTS: Of the 76 respondents 41 (53.9%) were female, 39.9% were community health extension workers, 26.3% were nurses/midwifes 30.3% lacked training on management of TB patient. Only 43.4% knew when to take action on patients who miss their drugs in the intensive phase, 30.3% and 35.5% knew defaults among category 1 and category 2 in the continuation phases of treatment respectively. They identified side effects of drugs (80%), daily clinic attendance (76.3%), health workers attitude (73.4%) and lack of knowledge on duration of treatment (71.1%) including their unfriendly attitudes towards the patients as the major barriers to patients' adherence to treatment. CONCLUSION: Lack of knowledge of the health care workers on management of TB patients and poor interpersonal relation and communication with patients have negative effect on patients' adherence to the long duration of TB treatment.

Methadone treatment improves tuberculosis treatment among hospitalized opioid dependent patients in Ukraine.

BACKGROUND: Ukraine's volatile syndemics of tuberculosis (TB) and HIV among people who inject drugs (PWIDs) introduces numerous treatment challenges for each condition, including high mortality and development of multi-drug resistant TB (MDR-TB). METHODS: A prospective, non-randomized 90-day observational study was conducted in six Ukrainian TB treatment sites to assess the effectiveness of integrating methadone maintenance (MMT) with TB treatment using: (1) 90-day TB treatment retention; (2) time to treatment discontinuation; (3) TB medication adherence; and (4) subject disposition, including mortality. Of the 110 participants enrolled, 57 received MMT and 53 did not (non-MMT). RESULTS: All of the primary outcomes were significantly better in MMT versus non-MMT groups, including 90-day TB treatment completion (89.5% versus 73.6%; p=0.031), time to TB treatment discontinuation (p=0.039) and TB medication adherence (97.1% versus 86.2%; p<0.001) after controlling for death. The major reasons for treatment non-completion in the non-MMT group included death (N=3), administrative discharge from the clinic (N=5), loss to follow-up (N=2), and arrest (N=4). Overall, 90-day mortality was high (8.2%). After controlling for covariates differing between the two groups at baseline, the only independent predictor of completing 90 days of TB treatment was receipt of MMT in an integrated treatment setting (AOR=3.05; 95% CI 1.08-8.66). CONCLUSIONS: MMT integrated into inpatient TB treatment significantly improves retention in TB treatment and TB medication adherence among PWIDs. These findings call for policy change to increase the number of MMT sites in TB facilities and make MMT a low-threshold treatment option for opioid dependence in Ukraine.

"Phthisiophobia": the difficult recognition of transmission of tuberculosis to health care workers.

BACKGROUND: Even if the contagious nature of tuberculosis was universally accepted during the nineteenth century, its transmission to health care workers (HCWs) was initially denied by the scientific community. Working among TB patients was not considered dangerous for healthy adults, so the potential risks for HCWs were branded as unwarranted "phthisiophobia" (fear of contracting tuberculosis). OBJECTIVES: This study aims at analyzing the problem of tuberculosis transmission among health care workers from an historical perspective, particularly highlighting the contribution made by the Italian Occupational Medicine community. METHODS: Scientific literature and historical sources on different theories regarding tuberculosis transmission were investigated, specially focusing on the period at the turn of the 19th and 20th centuries. RESULTS: At the beginning of the twentieth century, Luigi Devoto (1864-1936), an Italian pioneer in the field of Occupational Medicine, was one of the first scientists to conduct research on the transmission of tuberculosis among nurses. Since the 1920s several studies, conducted mainly on medical and nursing students, confirmed the risk for HCWs. However an international consensus on this issue was only achieved during the 1950s, when the institution of mandatory chest radiographs on admission for all patients significantly decreased the cases of tuberculosis among HCWs. CONCLUSIONS: Devoto was one of the first scholars who postulated the transmission of tuberculosis to HCWs. He also theorized that hospital personnel with active disease could also be a source of contagion to patients. Nowadays, "third party risk" and latent tuberculosis infection pose a new challenge for occupational physicians in hospitals.

TB questions, East Kwaio answers: community-based participatory research in a remote area of Solomon Islands.

INTRODUCTION: East Kwaio is a remote region on the island of Malaita, Solomon Islands. Atoifi Adventist Hospital (the Hospital) is the only hospital and tuberculosis (TB) services provider in the region. If people come to the Hospital with TB, they are usually admitted for the two-month intensive phase of treatment as there are no community-based TB services. Most people walk or travel by canoe to the Hospital as there are no roads. East Kwaio is known to have high rates of TB; however, it has a low case detection rate and low treatment completion. The aims of this study were to explore why people with TB, especially from the mountain areas, present to the Hospital so late in their illness or do not present at all. The study was part of a larger project to strengthen the research capacity of local health workers and community leaders, supported by visiting researchers from Australia. METHODS: Semi-structured interviews with TB patients, a focus group of key informants and direct interaction with a community with a history of TB were used to explore reasons why people present to the Hospital late in their TB illness. RESULTS: Four interviews and a focus group of 12 key informants were conducted and a mountain hamlet with a history of TB was visited. The results represent the data from the interviews and the focus group. The time delay in presenting to the Hospital from when participants first became unwell ranged between two and three years. In the mountain hamlet, two additional people with probable TB were seen who had not presented to the Hospital during illnesses of five and nine months. Reasons for delays included: seeking care from traditional healers; the challenge of accessing health services due to distance, cost and cultural issues different from the Hospital's worldview; social isolation when in hospital; and being old so not having long to live. Delays in diagnosis of people with TB will increase the risk of transmission to family and through hamlets and villages. This study has led to plans being developed to build a more culturally appropriate TB ward and community treatment program. CONCLUSIONS: The study has identified TB questions that need East Kwaio answers. It has shown that a small project can inform the development of important changes to TB services, such as the redevelopment and relocation of the TB ward. To enable TB control, the local health services need to develop an understanding of, and appropriately engage with, traditional beliefs that influence how people interact with Hospital TB treatment and management. This is the case even if the beliefs are based on a worldview different than that of the health service providers. Ongoing operational research is required into TB diagnosis and treatment services and the many factors that contribute to the high TB burden in this remote area.

The medicalization of sunlight in the early twentieth century.

This paper traces the emergence of the therapeutic use of sunlight in medicine during the first half of the twentieth century. This was a period of considerable flux in medicine with various strands of practice and theory competing. Drawing on two case studies of sunlight therapy, both artificial (actinotherapy) and natural (heliotherapy), in the treatment of rickets and tuberculosis this paper will explore how medicine was constituted within these regimes. The paper will argue that therapeutic and clinical applications of sunlight helped establish an association between sunlight and health but also defined a particular and specific performance of medicine.

Tuberculosis knowledge, attitudes and health-seeking behaviour in rural Uganda.

OBJECTIVES: To assess tuberculosis (TB) knowledge, attitudes and health-seeking behaviour to inform the design of communication and social mobilisation interventions. SETTING: Iganga/Mayuge Demographic Surveillance Site, Uganda. DESIGN: Between June and July 2008, 18 focus group discussions and 12 key informant interviews were conducted, including parents of infants and adolescents and key informant interviews with community leaders, traditional healers and patients with TB. RESULTS: People viewed TB as contagious, but not necessarily an airborne pathogen. Popular TB aetiologies included sharing utensils, heavy labour, smoking, bewitchment and hereditary transmission. TB patients were perceived to seek care late or to avoid care. Combining care from traditional healers and the biomedical system was common. Poverty, drug stock-outs, fear of human immunodeficiency virus (HIV) testing and length of TB treatment negatively affect health-seeking behaviour. Stigma and avoidance of persons with TB often reflects an assumption of HIV co-infection. CONCLUSION: The community's concerns about pill burden, quality of care, financial barriers, TB aetiology, stigma and preference for pluralistic care need to be addressed to improve early detection. Health education messages should emphasise the curability of TB, the feasibility of treatment and the engagement of traditional healers as partners in identifying cases and facilitating adherence to treatment.

Community perceptions of tuberculosis: A qualitative exploration from a gender perspective.

OBJECTIVE: To explore community laypersons' perspective on tuberculosis (TB)-related illness experiences, meanings, behaviours and impact with reference to gender. STUDY DESIGN: Qualitative, conducted in rural Bangladesh. METHODS: Eleven focus group discussions (FGDs) were conducted (six female and five male) in five subdistricts where the non-governmental organization BRAC operates. On average, seven purposively chosen poor, illiterate, non-TB patients participated in each FGD. Discussions were audiotaped, translated verbatim into English and analysed using MAXQDA software for qualitative data analysis, used it to assign codes to text segments to identify themes from participants' narratives. RESULTS: TB was recognized as a deadly disease that could affect anyone. The discussants were fairly aware of the psychological, financial and social impacts of TB. Women faced with adverse consequences more often than men, such as trouble in ongoing and prospective marital affairs. Coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. Women tended to describe the clinical features more vaguely than men, and often specified fewer characteristic symptoms such as blood in sputum. CONCLUSIONS: The gender differences in the health and socio-economic impact of TB included perceived causality, curability, stigma, family and community support, fear of disclosure, and use of self-help or home remedies. Interactive health education covering various consequences of TB could be indispensable to changing negative beliefs.

Children's role in enhanced case finding in Zambia.

OBJECTIVE: To evaluate information dissemination by children and attitudes among children towards a school-based tuberculosis (TB) reduction strategy that asked children to address TB symptoms, testing and stigma in their homes. SETTING AND DESIGN: Qualitative research was conducted with schoolchildren before, and 2 years into, an intervention to promote early detection of TB using sputum microscopy in Zambia. The baseline study in 2005 involved 38 children at five sites. The evaluation in 2008 included 209 children in schools at four sites. Research with schoolchildren included discussions, drawings, role plays and narratives. RESULTS: The baseline study revealed children's enthusiasm to learn about TB and the human immunodeficiency virus (HIV), but it also revealed children's anxieties about the possible conflicts related to discussing HIV and TB with adults. Children in the evaluation demonstrated more accurate knowledge about TB and HIV than in the baseline study. Children were enthusiastic about discussing TB and HIV at home. Their responses suggested that they did so with respect and adult approval, circumventing the intergenerational conflict expected during the baseline study. CONCLUSION: The present study demonstrates that schoolchildren have a role to play in enhanced case finding. Schoolchildren are already familiar with TB in areas of high burden, but they need more information about the link between TB and HIV and about antiretroviral treatment.

Health status of UK patients with active tuberculosis.

OBJECTIVE: To assess the impact of tuberculosis (TB) and its treatment on patients' health status. METHODS: Questionnaires were administered prospectively to patients at three clinics in London at diagnosis and 2 months into therapy. We assessed generic health-related quality of life (Short Form 36 [SF-36] and EQ-5D) and psychological burden (State-Trait Anxiety Short-Form, Center for Epidemiologic Studies Depression Scale, worry items). RESULTS: Of the 61 participants (response rate 94%), 89% were non-UK born, 67% had pulmonary TB and 38% were aged 30-45 years. At diagnosis, scores for all eight SF-36 dimensions were significantly worse than UK general population norm scores. At follow-up, scores had improved significantly (P < 0.01), except for physical functioning and general health perception, but remained below the UK norm, except for vitality and mental health. Respondents' mean anxiety and depression scores were high at diagnosis (48 and 22, respectively), and anxiety scores remained high at follow-up. Worries most frequently reported concerned patients' own health (92%) and that of their family (82%). CONCLUSIONS: TB patients suffer from significantly diminished health-related quality of life at diagnosis. Although treatment significantly improved patients' health status within 2 months, scores for many domains remain below UK norm scores. This emphasises the importance of a holistic approach to care and should inform the evaluation of future interventions.

Evaluating the policy of setting up microscopy centres at township hospitals in Shandong China: experience from patients and providers.

BACKGROUND: Since 2004 the China Ministry of Health policy has required microscopy centres (MCs) to be set up in one third of township hospitals nationally, to improve the accessibility of sputum smear testing for TB in rural areas. The objective of this study was to assess the performance of MCs in Shandong province from both patient and provider perspectives. METHODS: A survey of 245 TB suspects was conducted in 8 counties of Shandong stratified by MC performance. Seventy-two health providers and administrators were interviewed at the township and county levels. RESULTS: General performance of MC was poor. In 2006, the high and low performance groups checked on average 190 and 24 TB suspects, respectively. The majority of TB suspects who visited a MC did not have their sputum checked, or sputum was checked but the result was not recorded. TB suspects who visited a MC tended to live closer to it and had better knowledge of the MC than those who visited the county TB dispensary (CTD) directly. Patients with severe TB symptoms tended to go directly to the CTD. No significant difference in medical expenses before the TB diagnosis or diagnostic delay was found between TB suspects who visited a MC and those who did not. Several reasons were identified. The policy tried to set up too many MCs regardless of transportation conditions. It lacked operational details. Township hospitals had limited funding, qualified staff, and technical support from the CTD. The existing referral incentive discouraged sputum checks at the MC. CONCLUSION: The national MC policy fell short of its goals in Shandong. Neither patients nor providers were interested in using MC in its current form. Policy recommendations are given.

Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients: Design and Implementation.

BACKGROUND: While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder. METHODS: We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone. RESULTS: Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors. CONCLUSIONS: The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.

Social stigma and knowledge of tuberculosis and HIV among patients with both diseases in Thailand.

INTRODUCTION: Disease-related stigma and knowledge are believed to be associated with patients' willingness to seek treatment and adherence to treatment. HIV-associated tuberculosis (TB) presents unique challenges, because TB and HIV are both medically complex and stigmatizing diseases. In Thailand, we assessed knowledge and beliefs about these diseases among HIV-infected TB patients. METHODS: We prospectively interviewed and examined HIV-infected TB patients from three provinces and one national referral hospital in Thailand from 2005-2006. At the beginning of TB treatment, we asked patients standardized questions about TB stigma, TB knowledge, and HIV knowledge. Responses were grouped into scores; scores equal to or greater than the median score of study population were considered high. Multiple logistic regression analysis was used to identify factors associated with scores. RESULTS: Of 769 patients enrolled, 500 (65%) reported high TB stigma, 177 (23%) low TB knowledge, and 379 (49%) low HIV knowledge. Patients reporting high TB stigma were more likely to have taken antibiotics before TB treatment, to have first visited a traditional healer or private provider, to not know that monogamy can reduce the risk of acquiring HIV infection, and to have been hospitalized at enrollment. Patients with low TB knowledge were more likely to have severe TB disease, to be hospitalized at enrollment, to be treated at the national infectious diseases referral hospital, and to have low HIV knowledge. Patients with low HIV knowledge were more likely to know a TB patient and to have low TB knowledge. DISCUSSION: We found that stigma and low disease-specific knowledge were common among HIV-infected TB patients and associated with similar factors. Further research is needed to determine whether reducing stigma and increasing TB and HIV knowledge among the general community and patients reduces diagnostic delay and improves patient outcomes.