Afrique du Sud. La violence des personnels infirmiers a travers des entretiens individuels et de groupe, pour les soins en maternite. La violence est liee a au besoin d'identite professionnelles et de classe moyenne des soignants, et banalisee du fait de la non responsabilite du systeme et des cadres. Sous-tendue par l'idee d'une inferiorite des patients

Why do nurses abuse patients? Reflections from South African obstetric services - Social Science & Medicine - Vol. 47, 11 - ISBN: 02779536 - p.1781-1795

Title. Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis

Aim.  This paper reports the findings from a qualitative meta-synthesis concerning people with, or at risk of, tuberculosis, service providers and policymakers and their experiences and perceptions of tuberculosis and treatment.

Background.  Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves.

Method.  Qualitative systematic review methods were used to search, screen, appraise and extract data thematic analysis was used to synthesize data from 1990 to 2002, and an update of literature to December 2005. Two questions were addressed: ‘What does qualitative research tell us about the facilitators and barriers to accessing and complying with tuberculosis treatment?’ and ‘What does qualitative research tell us about the diverse results and effect sizes of the randomized controlled trials included in the Cochrane review?’ Findings help explain the diverse trial results in a Cochrane systematic review of directly observed therapy and tuberculosis and consider implications for research, policy and practice.

Findings.  Five themes emerged from the 1990 to 2002 synthesis: socio-economic circumstances, material resources and individual agency; explanatory models and knowledge systems in relation to tuberculosis and its treatment; the experience of stigma and public discourses around tuberculosis; sanctions, incentives and support, and the social organization and social relationships of care. Two additional themes emerged from the 2005 update.

Conclusion.  The qualitative meta-synthesis improved the relevance and scope of the Cochrane review of trials. The findings make a major contribution to the development of theory concerning global WHO-branded disease control and the practicality of local delivery to people.

Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis.

Proven effective interventions exist that would enable all countries to meet the Millennium Development Goals. However, uptake and use of these interventions in the poorest populations is at least 50% less than in the richest populations within each country. Also, we have recently shown that community effectiveness of interventions is lower for the poorest populations due to a "staircase" effect of lower coverage/access, worse diagnostic accuracy, less provider compliance and less consumer adherence. We propose an evidence-based framework for equity-oriented knowledge translation to enhance community effectiveness and health equity. This framework is represented as a cascade of steps to assess and prioritize barriers and thus choose effective knowledge translation interventions that are tailored for relevant audiences (public, patient, practitioner, policy-maker, press and private sector), as well as the evaluation, monitoring and sharing of these strategies. We have used two examples of effective interventions (insecticide-treated bednets to prevent malaria and childhood immunization) to illustrate how this framework can provide a systematic method for decision-makers to ensure the application of evidence-based knowledge in disadvantaged populations. Future work to empirically validate and evaluate the usefulness of this framework is needed. We invite researchers and implementers to use the cascade for equity-oriented knowledge translation as a guide when planning implementation strategies for proven effective interventions. We also encourage policy-makers and health-care managers to use this framework when deciding how effective interventions can be implemented in their own settings.

/pdf/systematic-reviews-and-knowledge-translation-2j8p1p0694.pdf

Systematic reviews and knowledge translation

OBJECTIVE: To assess whether adding a training intervention for clinic staff to the usual DOTS strategy (the internationally recommended control strategy for tuberculosis (TB)) would affect the outcomes of TB treatment in primary care clinics with treatment success rates below 70%. METHODS: A cluster randomized controlled trial was conducted from July 1996 to July 2000 in nurse-managed ambulatory primary care clinics in Cape Town, South Africa. Clinics with successful TB treatment completion rates of less than 70% and annual adult pulmonary TB loads of more than 40 patients per year were randomly assigned to either the intervention (n = 12) or control (n = 12) groups. All clinics completed follow-up. Treatment outcomes were measured in cohorts of adult, pulmonary TB patients before the intervention (n = 1200) and 9 months following the training (n = 1177). The intervention comprised an 18-hour experiential, participatory in-service training programme for clinic staff delivered by nurse facilitators and focusing on patient centredness, critical reflection on practice, and quality improvement. The main outcome measure was successful treatment, defined as patients who were cured and those who had completed tuberculosis treatment. FINDINGS: The estimated effect of the intervention was an increase in successful treatment rates of 4.8% (95% confidence interval (CI): -5.5% to 15.2%) and in bacteriological cure rates of 10.4% (CI: -1.2% to 22%). A treatment effect of 10% was envisaged, based on the views of policy-makers on the minimum effect size for large-scale implementation. CONCLUSION: This is the first evidence from a randomized controlled trial on the effects of experiential, participatory training on TB outcomes in primary care facilities in a developing country. Such training did not appear to improve TB outcomes. However, the results were inconclusive and further studies are required.

/pdf/staff-training-and-ambulatory-tuberculosis-treatment-55dibwqwsy.pdf

Staff training and ambulatory tuberculosis treatment outcomes: a cluster randomized controlled trial in South Africa

OBJECTIVES: To review the available published and non-published literature on patient empowerment in tuberculosis (TB) control, describe what it entails, identify possible trends and conclusions, and suggest areas both for informing policy makers and for orienting further research. METHODS: We searched MEDLINE and PSYCINFO databases, used World Wide Web research tools and included conference abstracts and specific project reports. RESULTS: Experience shows that operational definitions, potential barriers towards empowerment and contextual issues need to be considered. Four types of experiences were reported: (1) enabling patients to take more responsibility for their health, especially regarding adherence to treatment, (2) organizing TB patients into groups and clubs, (3) building patient-centred care in TB and general health services, and (4) using TB patients' advocacy skills to improve TB control. CONCLUSION: Patient empowerment conceptions through interventions and studies should primarily involve TB patients themselves. Patients' activism--their role, the shape it takes and resulting effects--is insufficiently documented

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3156.2007.01858.x

Patient empowerment in tuberculosis control: reflecting on past documented experiences.

Aim. This paper describes the development and implementation of an experiential, participatory in-service education programme focusing on patient-centeredness, problem-solving and critical reflection for primary providers delivering care to tuberculosis patients in South Africa.



Background.  Tuberculosis is a major contributor to the disease burden in developing countries. In South Africa, approximately 90% of tuberculosis patients are managed by nurses at the primary level. Despite efforts to improve quality of care for these patients, many fail to complete their treatment as prescribed. Poor rapport between health care providers and patients with tuberculosis is a major reason for non-adherence to treatment. Methods of improving the quality of care delivery and communication between health care providers and patients with tuberculosis is therefore a priority.



Discussion.  The paper outlines the stages of developing and implementing the education programme and reflects on this process. Data is drawn from an in-depth qualitative evaluation of the delivery and impacts of the intervention. The approach was acceptable to health care providers and adaptable to the needs of specific clinics. Participants evaluated the educational intervention positively, noting that it facilitated critical reflection on their work; encouraged problem-solving; and heightened their awareness of communication with patients and with colleagues. However, important structural barriers to practice change were identified, including conditions of service, relations with colleagues and support from management.



Conclusions.  Experiential, participatory in-service education can be implemented on a large scale in primary care settings. However, the process is resource intensive and the impacts of such education may be limited by barriers at other levels of the health system.

Elizabeth Rose

Papers

Changing professional practice in tuberculosis care: an educational intervention