Vinod K. Diwan

Gender and tuberculosis control Perspectives on health seeking behaviour among men and women in Vietnam

This study explores the perspectives of tuberculosis patients on which factors influenced their health seeking behaviour, with special reference to gender differentials in terms of delays in health seeking. In 1996, a multi-disciplinary research team carried out 16 focus group discussions. The study was done in four districts in Vietnam, both in the south and north of the country and in urban and rural areas. Qualitative analysis of data was performed following general principles of modified grounded theory technique. Participants in the focus groups described three main factors as contributing to delay in health seeking. These were fear of social isolation, economic constraints and inadequate staff attitudes and poor quality of health services. A model illustrating different factors influencing health seeking was elaborated and served as a basis for discussion of the findings. The main factor contributing to delay among women was described as fear of social isolation from the family or the community. Stigma was described as closely related to contextual factors such as gender-roles, socio-economic status and level of education and seemed to be mediated via denial and concealment of tuberculosis diagnosis and disease, thus causing delay. The main factor contributing to delay among men was described as fear of individual costs of diagnosis and treatment. Staff attitudes and quality of health service facilities were described as not always corresponding to peoples expectations of appropriate health services. Women saw themselves and were seen by others as being more sensitive than men to poor service conditions and staff attitudes. A typical feature of the described health seeking behaviour of men was that they neglected symptoms until the disease reached a serious stage, by which time they tended to go directly to public health services without first visiting private health practitioners. Women, on the other hand, were described as having a tendency to seek out private services and practice self-medication before seeking care at public services. In conclusion, there is a need for better understanding of behavioural factors and for developing strategies, that take these into account. Health workers need to better understand gender and social aspects of tuberculosis control, particularly aspects that influence the likelihood for achieving equity in diagnosis and cure.

Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis

SETTING The study was conducted in four districts in different regions of Vietnam. OBJECTIVE To describe the socio-economic consequences of tuberculosis (TB) in Vietnam with special reference to gender differentials concerning social stigma and isolation. DESIGN Sixteen focus group discussions were carried out with men and women, TB patients and non-TB participants. Data was analysed using modified grounded theory technique. RESULTS Generally, the participants had good knowledge about TB. However, knowledge and practice were not closely related in the sense that most non-TB participants perceived that TB can be successfully cured, while patients were seriously shocked when they were told that they had TB. Male patients often worried about economic-related problems, while female patients worried about social consequences of the disease. Both in the family and the community, isolation could be subtle, but it could also be obvious and had a tendency to continue much longer than medically justified. CONCLUSION Information on stigma and isolation due to TB and gender differences is important for understanding patient dynamics and its effects on the disease. Tuberculosis control programmes need better understanding of the gender differences in attitudes and beliefs to improve case-detection and treatment outcome.

FilaBavi, a demographic surveillance site, an epidemiological field laboratory in Vietnam

Background: This Supplement to the Scandinavian Journal of Public Health brings together a collection of community-based studies for which the common denominator is a demographic surveillance site, FilaBavi, established in northern Vietnam in 1999. This introductory paper sets out some of the background to FilaBavi as well as setting the scene for the individual studies.

Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam.

The objective of this study was to assess the effects of a multicomponent intervention on private pharmacy practice. From 641 private pharmacies in Hanoi, 68 pharmacies were randomly selected and matched into 34 pairs. Each pair consisted of a control and an intervention pharmacy. Three interventions were applied sequentially: Regulatory enforcement, Education, and Peer influence. Four tracer conditions were selected: uncomplicated acute respiratory infection (ARI), sexually transmitted disease (STD), requesting the prescription-only drugs prednisolone, and a short course of cefalexin. Practice was assessed through the Simulated Client Method (SCM). The intervention pharmacies improved significantly compared to the control pharmacies (P <.05) in all tracer conditions. For ARI, antibiotic dispensing decreased (P <.02) and questions regarding breathing increased (P <.01). For STD, advice to go to the doctor and dispensing the correct syndromic treatment increased (P <.01). Dispensing of prednisolone and cefalexin decreased (P <.01) and prescription requests increased (P <.01). Our conclusion is that it is possible to improve private pharmacy practice with a multicomponent intervention.

Design of a randomized trial to evaluate the influence of mobile phone reminders on adherence to first line antiretroviral treatment in South India - the HIVIND study protocol

BackgroundPoor adherence to antiretroviral treatment has been a public health challenge associated with the treatment of HIV. Although different adherence-supporting interventions have been reported, their long term feasibility in low income settings remains uncertain. Thus, there is a need to explore sustainable contextual adherence aids in such settings, and to test these using rigorous scientific designs. The current ubiquity of mobile phones in many resource-constrained settings, make it a contextually appropriate and relatively low cost means of supporting adherence. In India, mobile phones have wide usage and acceptability and are potentially feasible tools for enhancing adherence to medications. This paper presents the study protocol for a trial, to evaluate the influence of mobile phone reminders on adherence to first-line antiretroviral treatment in South India.Methods/Design600 treatment naïve patients eligible for first-line treatment as per the national antiretroviral treatment guidelines will be recruited into the trial at two clinics in South India. Patients will be randomized into control and intervention arms. The control arm will receive the standard of care; the intervention arm will receive the standard of care plus mobile phone reminders. Each reminder will take the form of an automated call and a picture message. Reminders will be delivered once a week, at a time chosen by the patient. Patients will be followed up for 24 months or till the primary outcome i.e. virological failure, is reached, whichever is earlier. Self-reported adherence is a secondary outcome. Analysis is by intention-to-treat. A cost-effectiveness study of the intervention will also be carried out.DiscussionStepping up telecommunications technology in resource-limited healthcare settings is a priority of the World Health Organization. The trial will evaluate if the use of mobile phone reminders can influence adherence to first-line antiretrovirals in an Indian context.Trial RegistrationTrial registration: ISRCTN79261738.

Can I afford free treatment? : Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam

Vietnam has a well-organised National TB Control Programme (NTP) with outstanding treatment results. Excellent prospect of cure is provided free of charge. Still, some people prefer to pay for their TB treatment themselves in private clinics. This is a potential threat to TB control since no notification of cases treated in the private sector occurs, and there is no control of the effectiveness of treatment provided in private clinics. Using a qualitative approach within a grounded theory framework, this study explores health-seeking behaviour among people with TB, applying a specific focus on reasons for choices of private versus pubic health care providers. The study identifies a number of characteristics of private TB care, which both seem attractive to patients and at the same time contrast sharply with the structure of the NTP strategy. These include flexible diagnostic procedures, no administrative procedures to establish eligibility for treatment, flexible choices of drug regimens, non-supervised treatment (no DOT), no tracing of defaulters in the household, no official registration of TB cases and thus less threat to personal integrity. A possibility to demand individualised service through the use of fee-for-service payments directly to physicians also seems attractive to many patients. A number of the components of the NTP strategy that have been put in place in order to secure optimal public health outcomes are lacking in the private sector. A dilemma for TB control is that this seems to be an important reason for why many people with TB opt for private providers where quality of care is virtually uncontrolled. The global threat of TB has led to calls for forceful measures to control TB. However, based on the findings in this study it is argued that the use of rigid approaches to TB control that do not encompass a strong component of responsiveness towards the needs of individuals may be counterproductive for public health.

High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand.

ObjectiveTo elicit community perceptions about tuberculosis (TB) and the behaviour of TB patients in an area where significant public health attention has been focused on AIDS. SettingChiang Rai, Thailand, the epicentre of HIV/AIDS in this country. DesignEleven focus group sessions with a cross-section of the population. ParticipantsHealth centre staff, community members, persons having HIV, TB patients (with and without HIV infection), and male injecting drug users; five female groups and six male groups. ResultPeople had good knowledge of AIDS but they knew little about TB. Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB and immediately sought care. People defined persons losing weight, having fever and cough as AIDS rather than TB. This resulted in delay in seeking care and non-adherence to TB treatment in some patients who suspected they had AIDS, and feared AIDS detection. Most HIV-negative TB patients were also suspected by their relatives and neighbours of having AIDS. Most participants, except HIV-positive females, believed TB to be curable. Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, foods and drinks and closeness to TB patients. ConclusionIn HIV/AIDS high endemic situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks

Aims: Good general lay knowledge of tuberculosis (TB), its cause and treatment is considered important for both prompt healthcare seeking and adherence to treatment. The main aim of this study was to describe the knowledge of TB among men and women with a cough for more than three weeks and to see how their health seeking related to TB knowledge. Methods: A population-based survey was carried out within a demographic surveillance site in Vietnam. The study population included 35,832 adults aged 15 years or over. Cough cases were identified at household level and structured interviews were carried out with all cases of cough in person. Results: A total of 559 people (1.6%) reported coughing with a duration of three weeks or longer (259 men and 300 women). A large proportion of individuals with a cough for more than three weeks had limited knowledge of the causes, transmission modes, symptoms, and curability of TB. Men had a significantly higher knowledge score than women (3.04 vs 2.55). Better knowledge was significantly related to seeking healthcare and seeking hospital care. More men than women did not take any health care action at all. Discussion: Health education for TB thus seems to be useful, but efforts must be made to ensure that both men and women in different socioeconomic contexts can access the information.

Seroprevalence of human immunodeficiency virus type 1 infection in zambian children with tuberculosis

Descriptions in the medical literature of human immunodeficiency virus type 1 (HIV-1) in children with tuberculosis (TB) are scanty. This study determined the seroprevalence of HIV-1 in 237 hospitalized children between the ages of 1 month and 14 years with a clinical diagnosis of TB (125 males and 112 females) and in 242 control children (149 males and 93 females). The overall HIV-1 seroprevalence rate in patients with TB was 37% (88 of 237) compared with 10.7% (26 of 242) among the control group (P < 0.00001: odds ratio 5.37, 95% confidence interval = 3.21 < 5.37 < 9.47). HIV-1 seropositivity in children with TB ranged from 53% (31 of 58) in the 12− to 18-month age group to 14% (9 of 61) in the 10− to 14-year-olds. The risk of TB attributable to HIV infection was 29%. The predominant clinical presentation in both seronegative (84.6%) and seropositive (89.7%) groups was that of pulmonary TB and there were no significant differences in clinical presentation between the two groups of patients. Only 54.8% of the patients attended follow-up clinics regularly whereas 32% were lost to follow-up within 3 months. Bacillus Calmette-Guérin vaccination coverage was 87.3% among TB patients and 90.5% in the controls. No significant differences in B. Celmette-Guérin vaccination rates between the seronegative and seropositive children were seen. Coinfection with HIV and TB in children is now one of the major public health problems in Zambian children.

Influencing Prescribing for Urinary Tract Infection and Asthma in Primary Care in Sweden: A Randomized Controlled Trial of an Interactive Educational Intervention

Our aim was to evaluate effects on prescribing for urinary tract infection (UTI) and asthma, of an education with messages based on national guidelines, aimed at improving prescribing in primary care in Sweden. The study is part of the European Drug Education Project. A randomized controlled trial, with groups of general practitioners (GPs) allocated to education on UTI (18 groups, 104 GPs) or asthma (18 groups, 100 GPs), the two parallel intervention arms being controls for each other. Feedback was provided on the GPs judgments of simulated cases and prescribing. Prescribing indicators were developed and measured before and after the intervention. Analysis was performed by multi-level technique. Prescribing of first choice UTI drugs increased in the intervention arm from 52% to 70% and remained constant in the control arm (P < 0.001). The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms. The educational model can be used to improve prescribing. Further studies are needed to define when the model is effective.