Social impact of tuberculosis in southern Thailand: views from patients, care providers and the community.

BACKGROUND: There is growing recognition that attention to social and behavioral factors in tuberculosis (TB) control needs to complement biomedical emphasis on better drugs, vaccines and new diagnostic tools. METHODS: Using qualitative methods, we conducted 10 focus groups and seven individual interviews to explore how TB is perceived or experienced in southern Thailand. Participants included male and female patients with TB, patients with AIDS, TB care providers, family members of patients with TB, religious leaders (Buddhist and Muslim), and unaffected community members. RESULTS: Responses informed two conceptual frameworks on stigma and social support. The first model dichotomized the meaning of TB into 'good' and 'bad' factors related to social support and stigma, respectively. The second model identified three themes--disease severity, religion, and knowledge of TB--linked to either stigma, social support, or both. CONCLUSION: Social support as a facilitator and stigma as a barrier are diametrically opposed concepts that need to inform TB care and treatment. Interventions to reduce stigma and promote social support at the patient, household, community, and health care system levels should be part of future efforts in the control of TB in Thailand.

Randomized controlled trial of directly observed treatment (DOT) for patients with pulmonary tuberculosis in Thailand.

While directly observed treatment (DOT) has been recommended as the standard approach to tuberculosis control, empirical data on its feasibility and efficiency are still scarce. We conducted a controlled trial of DOT at 15 health care facilities at various levels of the government health care system in Thailand. A total of 836 patients diagnosed between August 1996 and October 1997 were randomly assigned to be treated either under DOT or self-supervised using monthly drug supplies (SS). Options for treatment supervisors were health staff, community members or members of the patients' families. Treatment outcomes were compared on the basis of cure, treatment-completion, default and death rates. In both study arms, treatment outcomes were improved compared to pre-study conditions. Cure and treatment-completion rates were significantly higher in the DOT cohort (76% and 84%) than in the SS group (67% and 76%). The benefits of DOT were more pronounced at district and provincial hospitals (DOT cure rate 81% vs. 69% in the SS group), while differences for patients treated at referral centres were non-significant (DOT cure rate 72% vs. 66% in the SS group). No significant differences in outcomes could be observed between patient groups receiving DOT under the various options for treatment supervisors. DOT appears especially suited for treatment at decentralized facilities. While a general focus on programme performance can improve outcomes, DOT provides significant additional benefits. If basic conditions are met, a DOT strategy can be tailored to country-specific conditions by exploring multiple observation options, without decreasing its effectiveness.