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Adapting a generic tuberculosis control operational guideline and scaling it up in China: a qualitative case study

26 Aug 2008

Maristela Martins de Camargo and Marcia Triunfol

Source: BMC Public Health (see original article)

Citation: Wei X, Walley JD, Liang X, Liu F, Zhang X, Li R. Adapting a generic tuberculosis control operational guideline and scaling it up in China: a qualitative case study. BMC Public Health. 2008 Jul 29;8(1):260.

The integration of medical research findings into effective public health policies is a process that presents many challenges, especially if one considers the cultural background and socio-economical characteristics of both patients and health care staff. Aimed to facilitate this process, the World Health Organization (WHO) has developed several generic management guidelines, to be adapted by each country in order to better suit their particular characteristics and needs. One of these guidelines is the WHO tuberculosis (TB) treatment guideline, which has been further developed into a generic TB operational ‘deskguide’ by the Nuffield Centre for International Health and Development at the University of Leeds (1).

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, which is transmitted by social contact, through coughing or spitting. Tuberculosis treatment requires the patient to take a large number of tablets every day for 6-8 months, on average. This long-term treatment is hard to adhere to and requires extra patient support. Although curable, tuberculosis patients carry an extra burden as, in certain societies, they are singled out and isolated from social interaction. The stigma of having been infected by M. tuberculosis contributes to a delay in seeking treatment and in an overall low adherence rate to treatment.

Wei and collaborators tried to adapt the generic guidelines published by the Nuffield Centre for International Health and Development (1) to the socio-economic characteristics of the Chinese population. The researchers report their efforts in training TB doctors in two chosen locations in China (one that represented a poorer area and another a richer one) and describe how the introduction of the custom-adapted deskguide impacted each of the two pilot locations, when compared to control sites that were selected within the same regions.

In the pilot areas, the adapted deskguide was used in training workshops for staff members directly involved in TB control. Two weeks after the initial training, researchers performed follow-up visits to address problems using the deskguide. One important modification of the procedures adopted in China was the selection of one family member for each TB patient as a treatment supporter. Control sites were also subjected to training workshops and follow-up visits but these were of a different nature to those offered in the pilot areas as, in the control sites, only the China National Policy Guide for TB management was used. In control areas, village doctors were the only people requested to act as treatment supporters of TB patients and to ensure that patients took their daily medicine.

The authors’ findings show that, once the initial barrier of adopting new procedures was overcome, those areas where the adapted deskguide was applied achieved higher rates of treatment adherence. Another point observed by these authors was the significant increase in time that TB doctors started to spend explaining to patients about the disease and the importance of long-term treatments. The study also found that active dissemination methods (such as in-site training of health personnel, follow-up meetings for reinforcement of the new practice adoption, distribution of patient educational material and active recruitment of one family member to act as a patient’s treatment supporter) resulted in better TB treatment standards in the pilot areas, as opposed to control areas that were left to their own dynamics. These changes were seen regardless of whether the pilot areas were located in poor or rich counties.

It is undeniable that a health practitioner who spends more time with his/her patient will most likely have a positive impact in the overall rate of success of the treatment, regardless of the disease being treated. For those health policy makers willing to adapt these guidelines to their local conditions, this study provides some starting points and first steps that are worth considering.

Reference

1. Nuffield Centre for International Health and Development. Generic guidelines for community based TB DOTS, 2004. Available at: http://www.leeds.ac.uk/lihs/nuffield/research/guidelines_TBDOTS.htm.

© 2008 Wei et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Source

Title:
Adapting a generic tuberculosis control operational guideline and scaling it up in China: a qualitative case study.

Authors:
Wei X, Walley JD, Liang X, Liu F, Zhang X, Li R

References:
BMC Public Health 2008: Vol. 8, pp. 260

Abstract:
BACKGROUND: The TB operational guideline (the deskguide) is a detailed action guide for county TB doctors aiming to improve the quality of DOTS, while the China national TB policy guide is a guide to TB control that is comprehensive but lacks operational usability for frontline TB doctors. This study reports the process of deskguide adaptation, its scale-up and lessons learnt for policy implications. METHODS: The deskguide was translated, reviewed, and revised in a working group process. Details of the eight adaptation steps are reported here. An operational study was embedded in the adaptation process. Two comparable prefectures were chosen as pilot and control sites in each of two participating provinces. In the pilot sites, the deskguide was used with the national policy guide in routine in-service training and supervisory trips; while in the control sites, only the national policy guide was used. In-depth interviews and focus groups were conducted with 16 county TB doctors, 16 township doctors, 17 village doctors, 63 TB patients and 57 patient family members. Following piloting, the deskguide was incorporated into the national TB guidelines for county TB dispensary use. RESULTS: Qualitative research identified that the deskguide was useful in the daily practice of county TB doctors. Patients in the pilot sites had a better knowledge of TB and better treatment support compared with those in the control sites. CONCLUSION: The adaptation process highlighted a number of general strategies to adapt generic guidelines into country specific ones: 1) local policy-makers and practitioners should have a leading role; 2) a systematic working process should be employed with capable focal persons; and 3) the guideline should be embedded within the current programmes so it is sustainable and replicable for further scale-up.

PMID: 18662410
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