Authors

1. Peruhype, Rarianne Carvalho
2. Bath-Hextall, Fiona
3. Galvao, Cristina Maria
4. Darlington, Nicola
5. Palha, Pedro Fredemir

Abstract

Review question/objective: What are the most effective educational interventions that are used to improve patients' outcomes via improvement of health professionals' knowledge and practice in the Direct Observed Therapy of Tuberculosis and the Directly Observed Therapy Short-Course (DOTS) strategy?

Background: Tuberculosis (TB) is a major concern for global public health. Although considered a curable disease, its incidence has continued to rise in certain regions. In Europe, for example, the rates of reported cases of TB (per 100,000 inhabitants) have increased considerably, ranging from 74.4 in 1997 to 104 in 2004. There are great disparities among countries in this continent with respect to TB infection. While Ireland and England showed less than 13 cases per 100,000 inhabitants in 2004, Romania and Russia had more than 100 estimated cases of TB per 100,000 inhabitants and the European part of Kazakhstan had 216 cases per 100,000 inhabitants, in the same period.1 India and China reported incidence rates of TB around 168/100,000 and 102/100,000 inhabitants in 2003, while Zimbabwe and Kenya presented even more concerning figures of 659/100,000 and 610/100,000 cases of all forms of TB, respectively.2

According to the 2011 World Health Organization (WHO) report, "India and China accounted for 40% of the world's notified cases of TB in 2010; Africa accounted for a further 24% of which one quarter were in South Africa and the 22 high-TB burden countries accounted for 82% of all notified cases in the world".^3(p28) In 2011, there were approximately nine million new cases of TB and 1.4 million deaths associated with the disease worldwide.4

Aware of the alarming condition of the disease around the world and aiming to decrease the incidence and the global spread of TB, in 1997 the WHO promoted the Direct Observed Treatment Short Course (DOTS), one of the components of The Stop TB Partnership's 'Global Plan to Stop TB 2011-2015'.5

The DOTS strategy consists of five elements stated by WHO as: 1) Political commitment with increased and sustained financing; 2) Case detection through quality-assured bacteriology; 3) Standardized treatment, with supervision and patient support; 4) An effective drug supply and management system and 5) Monitoring and evaluation system, and impact measurement.6 Standardized treatment, known also as Direct Observed Therapy or Supervised Treatment/Therapy of TB, can be described as the activity of systematically and regularly monitoring the anti-TB drug intake by the patient. It can be performed by any health professional (physician, nurses, technicians, etc.) or any other provider (relatives, community members, cured TB patients, neighbors, or friends) who are trained and qualified to undertake this activity. Supervision can be undertaken at a health facility, in the workplace, in the community or at home.7,8

The WHO assigns the training and monitoring activities of non-medical treatment observers to the National Tuberculosis Control Program (NTP):

"There must be a clearly defined line of accountability from NTP staff to general health service staff and the treatment supporter[horizontal ellipsis] Detailed instructions for informing the patient and family about TB and its treatment and for arranging supervised treatment (including identifying and preparing a community TB treatment supporter) are contained in WHO's training modules for health facility staff".^7(p78)

Guidelines on supervised treatment, TB control and community involvement can be found at the WHO databases and can underpin training processes.

Regarding the importance of undertaking DOTS, evidence suggests that it is possible to achieve up to a 90% cure rate when anti-TB drugs are correctly used.9 Supervised treatment is therefore an important strategy to not only ensure drug ingestion by the patient, but also to promote adherence to treatment, to increase the chances of cure and to decrease the odds of probable drug resistance, which seems to be the major consequence in contexts of noncompliance by the patient.10 In San Francisco, California, for example, the proportion of cure, mortality due to TB and drug resistance in 149 patients with pulmonary TB using supervised treatment was respectively 97.8%, 0% and 0%, while those undergoing self-administered therapy (223 patients) achieved 88.6% (cure), 5.5% (mortality due to TB) and 0.9% (drug resistance).11 In Sao Jose do Rio Preto, Brazil, the percentage of cure increased from 61.06% (1998) to 69.85% (2003) and the noncompliance with drug treatment reduced from 18.7% to 1.5% after the supervised treatment implementation in health services.12

Since the adoption of the DOTS strategy and the stop TB partnership plan, many countries have seen a notable reduction in the number of TB cases and deaths related to TB. The WHO Global Tuberculosis Report 2012 stated that "between 1995 and 2011, 51 million people were successfully treated for TB in countries that had adopted the DOTS/stop TB strategy (out of a total of 60 million treated)".^4(p31) TB mortality rate has decreased by 41% since 1990 and the world seems to be in the right path to achieve the global targets of a 50% reduction by 2015. TB incidence rate (including HIV) in the Americas, for example, decreased from 59/100,000 inhabitants (1990) to 28/100,000 (2011). In the Western Pacific this rate reduced from 159/100,000 (1990) to 92/100,000 (2011).4 In Peru, the use of DOTS for more than five years resulted in successful treatment of 91% of cases.13

However, TB incidence still remains high in some continents such as in Africa, where the TB incidence rate increased from 245/100,000 inhabitants (1990) to 262/100,000 (2011).4 According to the 2007 WHO report, until 2005 there were still 25 out of 212 WHO member states which had not adopted the DOTS strategy,14 which perhaps influences the TB rates in those countries.

Thus, acknowledging the important contribution that the DOTS strategy, and particularly supervised treatment, can make in combating tuberculosis and increasing cure, this review will investigate the educational methods used by health institutions or health authorities to enhance the knowledge of health professionals, whether in the overall DOTS strategy or only in the supervised treatment of tuberculosis and how it can impact on TB cases as well on patient related outcomes such as cure, compliance, mortality and dropout rates.

It is known that the qualification of human resources in health or the lack of it can vastly influence TB rates. Accordingly to Munoz et al., 18 out of the 22 NTP managers of the TB high-burden countries ranked inappropriate human resources as the top constraint in order to reach the WHO global TB control objectives.15 The lack of adequately qualified or trained staff at different service levels was emphasized among other aspects.

In fact, information transfer and sharing, when appropriately done, can generate relevant knowledge which can then be converted into innovative actions by the health professionals in their workplaces. Albagli and Maciel believe in the "inseparability among the cognitive, informational, innovative and sociospatial dynamic" and claim that the use of information, knowledge and production of innovations can be characterized as a sociocultural process, bounded by a space and its own creation.16

Thus the analysis of the educational interventions used in health professionals' training on the DOTS strategy and supervised treatment can be seen as an opportunity to investigate not only the results of applying the theoretical knowledge in practice and the probable influence on TB incidence rates and patient-related outcomes, but also an opportunity to assess what type of educational measures were considered more suitable and effective in certain health contexts. On this regard, there will probably have been several and different training designs/types of educational interventions and also a variety of trainers, which could perhaps change from place to place, health institution to health institution, or from country to country, for example.

It is important to mention that in this review, educational intervention will be considered as any type of information or communication resource such as printed and illustrative material (flipcharts, posters, pamphlets, flyers, guidelines), educational workshops and meetings, lectures and seminars, among others.

A preliminary search of the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, the Cochrane Library, CINAHL, PubMed and PROSPERO has revealed that there is not currently a systematic review, either published or underway, on this topic.