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      Adherence to Multidrug Resistant Tuberculosis Treatment and Case Management in Chongqing, China – A Mixed Method Research Study

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          Abstract

          Aim

          This paper evaluated the treatment adherence for multidrug-resistant tuberculosis (MDR-TB) and MDR-TB case management (MTCM) in Chongqing, China in order to identify factors associated with poor treatment adherence and case management.

          Methods

          Surveys with 132 MDR-TB patients and six in-depth interviews with health care workers (HCWs) from primary health centers (PHC), doctors from MDR-TB designated hospitals and MDR-TB patients were conducted. Surveys collected demographic and socio-economic characteristics, as well as factors associated with treatment and case management. In-depth interviews gathered information on treatment and case management experience and adherence behaviors.

          Results

          Patient surveys found the two main reasons for poor adherence were negative side-effects from the treatment and busy work schedules. In-depth interviews with key stakeholders found that self-perceived symptom improvement, negative side-effects from treatment and financial difficulties were the main reasons for poor adherence. MDR-TB patients from urban areas, who were unmarried, were female, had migrant status, and whose treatments were supervised by health care workers from primary health clinics, had poorer treatment adherence (P<0.05). Among the MDR-TB patients surveyed, 86.7% received any type of MTCM in general (received any kind of MTCM from HCWs in PHC, MDR-TB designated hospital and centers of disease control/TB dispensaries and 62.50% received MTCM from HCWs in PHC sectors). Patients from suburban areas were more likely to receive both MTCM in general (OR=6.70) and MTCM from HCWs in MDR-TB designated hospitals (OR=2.77), but female patients (OR=0.26) were less likely to receive MTCM from HCWs in PHC sectors, and patients who were not educated about MTCM by TB doctors in designated hospitals were less likely to receive MTCM in general (OR=0.14). Patients who had not been hospitalized were less likely to receive MTCM from HCWs in MDR-TB designated hospitals (OR=0.21).

          Conclusion

          Stronger MTCM by HCWs in PHC sectors would improve treatment adherence among MDR-TB patients. Community-based patient-centered models of MTCM in PHC sectors and the use of digital health technology could help to improve case management and thereby improve adherence.

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          Most cited references40

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          Qualitative data analysis: the framework approach.

          Qualitative methods are invaluable for exploring the complexities of health care and patient experiences in particular. Diverse qualitative methods are available that incorporate different ontological and epistemological perspectives. One method of data management that is gaining in popularity among healthcare researchers is the framework approach. We will outline this approach, discuss its relative merits and provide a working example of its application to data management and analysis.
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            Using Framework Analysis in nursing research: a worked example.

            To demonstrate Framework Analysis using a worked example and to illustrate how criticisms of qualitative data analysis including issues of clarity and transparency can be addressed. Critics of the analysis of qualitative data sometimes cite lack of clarity and transparency about analytical procedures; this can deter nurse researchers from undertaking qualitative studies. Framework Analysis is flexible, systematic, and rigorous, offering clarity, transparency, an audit trail, an option for theme-based and case-based analysis and for readily retrievable data. This paper offers further explanation of the process undertaken which is illustrated with a worked example. Data were collected from 31 nursing students in 2009 using semi-structured interviews. The data collected are not reported directly here but used as a worked example for the five steps of Framework Analysis. Suggestions are provided to guide researchers through essential steps in undertaking Framework Analysis. The benefits and limitations of Framework Analysis are discussed. Nurses increasingly use qualitative research methods and need to use an analysis approach that offers transparency and rigour which Framework Analysis can provide. Nurse researchers may find the detailed critique of Framework Analysis presented in this paper a useful resource when designing and conducting qualitative studies. Qualitative data analysis presents challenges in relation to the volume and complexity of data obtained and the need to present an 'audit trail' for those using the research findings. Framework Analysis is an appropriate, rigorous and systematic method for undertaking qualitative analysis. © 2013 Blackwell Publishing Ltd.
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              Effectiveness of Electronic Reminders to Improve Medication Adherence in Tuberculosis Patients: A Cluster-Randomised Trial

              Background Mobile text messaging and medication monitors (medication monitor boxes) have the potential to improve adherence to tuberculosis (TB) treatment and reduce the need for directly observed treatment (DOT), but to our knowledge they have not been properly evaluated in TB patients. We assessed the effectiveness of text messaging and medication monitors to improve medication adherence in TB patients. Methods and Findings In a pragmatic cluster-randomised trial, 36 districts/counties (each with at least 300 active pulmonary TB patients registered in 2009) within the provinces of Heilongjiang, Jiangsu, Hunan, and Chongqing, China, were randomised using stratification and restriction to one of four case-management approaches in which patients received reminders via text messages, a medication monitor, combined, or neither (control). Patients in the intervention arms received reminders to take their drugs and reminders for monthly follow-up visits, and the managing doctor was recommended to switch patients with adherence problems to more intensive management or DOT. In all arms, patients took medications out of a medication monitor box, which recorded when the box was opened, but the box gave reminders only in the medication monitor and combined arms. Patients were followed up for 6 mo. The primary endpoint was the percentage of patient-months on TB treatment where at least 20% of doses were missed as measured by pill count and failure to open the medication monitor box. Secondary endpoints included additional adherence and standard treatment outcome measures. Interventions were not masked to study staff and patients. From 1 June 2011 to 7 March 2012, 4,292 new pulmonary TB patients were enrolled across the 36 clusters. A total of 119 patients (by arm: 33 control, 33 text messaging, 23 medication monitor, 30 combined) withdrew from the study in the first month because they were reassessed as not having TB by their managing doctor (61 patients) or were switched to a different treatment model because of hospitalisation or travel (58 patients), leaving 4,173 TB patients (by arm: 1,104 control, 1,008 text messaging, 997 medication monitor, 1,064 combined). The cluster geometric mean of the percentage of patient-months on TB treatment where at least 20% of doses were missed was 29.9% in the control arm; in comparison, this percentage was 27.3% in the text messaging arm (adjusted mean ratio [aMR] 0.94, 95% CI 0.71, 1.24), 17.0% in the medication monitor arm (aMR 0.58, 95% CI 0.42, 0.79), and 13.9% in the combined arm (aMR 0.49, 95% CI 0.27, 0.88). Patient loss to follow-up was lower in the text messaging arm than the control arm (aMR 0.42, 95% CI 0.18–0.98). Equipment malfunction or operation error was reported in all study arms. Analyses separating patients with and without medication monitor problems did not change the results. Initiation of intensive management was underutilised. Conclusions This study is the first to our knowledge to utilise a randomised trial design to demonstrate the effectiveness of a medication monitor to improve medication adherence in TB patients. Reminders from medication monitors improved medication adherence in TB patients, but text messaging reminders did not. In a setting such as China where universal use of DOT is not feasible, innovative approaches to support patients in adhering to TB treatment, such as this, are needed. Trial Registration Current Controlled Trials, ISRCTN46846388
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                Author and article information

                Journal
                Infect Drug Resist
                Infect Drug Resist
                idr
                idr
                Infection and Drug Resistance
                Dove
                1178-6973
                15 March 2021
                2021
                : 14
                : 999-1012
                Affiliations
                [1 ]Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University) , Chongqing, People’s Republic of China
                [2 ]Duke Kunshan University , Kunshan, Jiangsu, People’s Republic of China
                [3 ]Department of Districts and Counties, Chongqing Institute of TB Prevention and Treatment , Chongqing, People’s Republic of China
                [4 ]Duke Global Health Institute, Duke University , Durham, NC, USA
                [5 ]Chongqing Institute of TB Prevention and Treatment , Chongqing, People’s Republic of China
                Author notes
                Correspondence: Shenglan Tang Duke Global Health Institute, Duke University , Durham, NC, USA Email shenglan.tang@duke.edu
                Ying Li Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University) , Chongqing, People’s Republic of China Email Lilyliying2012@163.Com
                [*]

                These authors contributed equally to this work

                Author information
                http://orcid.org/0000-0002-5643-6255
                http://orcid.org/0000-0002-8942-1957
                Article
                293583
                10.2147/IDR.S293583
                7979342
                33758516
                5f04df69-1e83-4ae6-b7de-84c41ed1ef02
                © 2021 Xing et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 23 November 2020
                : 18 February 2021
                Page count
                Figures: 3, Tables: 10, References: 42, Pages: 14
                Funding
                Funded by: the National Natural Science Foundation of China;
                Funded by: the Chongqing outstanding youth project;
                Funded by: Social Science and Technology Innovation Subject in Chongqing;
                This project was funded by the National Natural Science Foundation of China (No. 81773489), the Chongqing outstanding youth project (cstc2020jcyj-jqX0007), Social Science and Technology Innovation Subject in Chongqing (No. cstc2015shmszx120070), and the 2019 Chongqing Municipal Health and Health Committee & Chongqing Science and Technology Bureau Joint Medical Research Project (No. 2019MSXM095). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Original Research

                Infectious disease & Microbiology
                multi-drug-resistant tuberculosis,management,treatment,adherence behaviors

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