3Ts of low cure rate: taxonomy, themes and theory of low cure rate in Pakistan’s TB control programme and gathering a 360-degree perspective through qualitative, in-depth interviewing approach

Abstract

ObjectiveWHO recommends cure of tuberculosis (TB) as the best prevention strategy; however, information about factors associated with low cure rate in patients with drug-susceptible TB is limited in Pakistan. Therefore, the purpose of this study was to explore the factors that account for low TB cure rate.MethodologyThe present qualitative study recruited diverse informants through purposive sampling to explore low cure rate situation in Badin between March and June 2017. Data were collected from clinicians, paramedics, lab technicians, district field supervisors, patients and treatment supporters through indepth and face-to-face interviews. Interviews were conducted in local languages (Urdu and Sindhi) and transcribed into English. Coding structure was developed inductively and applied on textual data to draw output at the levels of taxonomy, themes and theory, as proposed by Bradleyet al.FindingsThirty-seven individuals consented to participate in this study and provided detailed account of the subject under enquiry. Review of interview data collected from a variety of informants resulted in the identification of four broad factors (taxonomy) that contributed to the situation of low cure rate in one of the districts implementing the public–private mix intervention. These factors were (1) health-seeking behaviour, (2) technical capacity of the healthcare provider, (3) managerial capacity of the healthcare provider, and (4) access to healthcare facility and services. Each factor is deconstructed into key dimensions (themes) that emerged from the dialogue between the interviewer and the respondents. Moreover, dimensions were exemplified through underlying concepts that correspond to theories for low cure rate.ConclusionChange in programme reporting requirement has demeaned the significance of having cure as treatment outcome. Therefore, returning the focus to achieving cure status for TB cases will be beneficial for assessing the effectiveness of TB control efforts. In parallel to the care delivery system, a mechanism for disseminating disease-related and treatment-related information should be introduced.

Patient adherence to tuberculosis treatment in the Indian subcontinent: systematic review and meta-synthesis of qualitative research

“…In the competition to achieve this, healthcare providers often neglected the needs of patients and this lead to strained relationships 44 46 52 62–64 67 and poor accountability towards those taking treatment. 55 67 In some of the DOT setups, monitoring adherence entailed the provider visiting patients at their homes 53 60 62 which was not acceptable to several as this divulged their disease and treatment status. 49 51 52 57 62 63 67 In this context, phone reminders were considered better by the persons on treatment.…”

“…For those who were the main breadwinners of their families, their nature of employment and the flexibility or understanding extended by their employers influenced their ability to access and continue treatment. Especially for daily-wage workers, this boiled down to having to make a choice between going to work and getting treatment 45–59. Lack of livelihood impacted their entire families; lack of treatment was seen as something that only they needed to deal with.…”

“…Long-term impact of the disease, and its consequent effect on the person and their families were not understood or considered in the context of the difficulties of their immediate realities. In such circumstances, several even resorted to private sector for treatment since it did not have the same restrictions in terms of accessing treatment as the public sector 45 51 52 55 60–62. Contexts in which this was taken into account and made flexible was seen as a great facilitator for access and adherence to treatment 63.…”

“…This was evident through programmatic algorithms, and through responses from persons taking treatment and treatment providers. This was exacerbated by inadequate infrastructure46 47 54 55 57 60 67 and administration,49 50 53 55 57 67 lack of access to care46 47 54 55 57 60 62 66 67 as well as demanding treatments for TB57 58 63 67 in terms of the duration,46 50 53 59 60 64 pill burden,50 52 64 adverse events from the medication,44 46 50 52–54 58 62 63 lack of nutritional supplementation to support treatment45 46 50 54 59 and the monetary deficit45 46 48 50 52 53 57 to address some of these issues.…”

“…Programme staff reported lack of training related to programme implementation,50 55 57 60 64 67 insufficient human resources 50 51 53 56 60 66 leading to inadequate monitoring of both treatment46 53 66 67 and of adverse events following medication 52 54 55 58 63. Staff reported being overburdened with achieving ‘targets’ ,47 55 66 67 which were always black-and-white vis-à-vis treatment outcome and in what was measured as a ‘success’.…”