ORIGINAL RESEARCH

Health personnel's views of directly observed treatment of tuberculosis

Hellen Pollyanna Mantelo Cecilio^I; Sonia Silva Marcon^II

^I Master in Nursing. State University of Maringa. Maringa, Parana, Brazil. E-mail: pollymantelo@gmail.com
^II PhD in Nursing. State University of Maringa. Maringa, Parana, Brazil. E-mail: soniasilva.marcon@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.8425

ABSTRACT

Objective: to discover the opinions of directly observed treatment for tuberculosis. Method: qualitative, descriptive study held by primary care nurses and doctors in the 15 municipalities that make up the 15th Health Region of Paraná State. Data were collected by semi-structured interviews of 20 nurses and 10 physicians working in tuberculosis control actions in June and July 2013. Content analysis yielded the category Directly observed treatment: strengths and weaknesses. Results: although, due to the low number of cases, directly observed treatment is not implemented in all municipalities, practitioners do recognize its importance. However, difficulties in implementing the strategy include lack of time, human resources and transport. Conclusion: in this regard, it is essential to improve health service organization and delivery.

Keywords: Tuberculosis; directly observed therapy; primary health care; nursing.

INTRODUCTION

In 1993, the World Health Organization declared emergency situation of tuberculosis in the world, including it in the agenda of priorities of public health policies¹. In Brazil, due to the epidemiological and health profile, characterized by the presence of chronic and infectious diseases concomitantly, the Ministry of Health pointed out the need of reorganization of the health care model². Thus, in 1998, along with the implementation of the National Program for Tuberculosis Control (PNCT in Portuguese), it was also implemented the directly observed treatment (DOT), in order to reduce morbidity and mortality and disease transmission³.

The DOT is a pillar of the DOTS (Directly Observed Treatment Short-course) strategy, internationally recommended, which acts as an important tool to reduce drug resistance, encourage adherence and reduce treatment abandonment^3,4. In the current situation of combat to tuberculosis, the abandonment of treatment remains as a major challenge for the Brazilian health system ⁴, which since 2000, extended its actions to primary care, aiming at a joint with the family health strategy (ESF in Portuguese) in order to expand the DOT for the whole country ³.

In short, it was established the hierarchy of health and the responsibility of tuberculosis control was assigned to the municipalities, as a competence of primary care^2,5. In this process, the ESF has become the center of the action, promoting access and quality care to users and strengthening the principles of comprehensiveness and fairness of the National Health System. Thus, it is known that the ESF has a privileged place, in knowing individuals and families, identifying problems and risk situations in the territory covered, developing activity programs to meet the health needs, planning and implementing educational activities and providing comprehensive care to the families⁶.

In the case of tuberculosis, the ESF must be prepared also for the realization of the DOT in a location chosen by the patient. Thus, this highlights the need for investment in interventions that increase the effectiveness of public health programs, which requires a knowledge that is closer of the reality, of the day-to-day of patients, nurses, doctors and other health professionals and also of health services⁷. Thus, this study aimed to know the opinion of health professionals on the directly observed treatment of tuberculosis.

THEORETICAL FRAMEWORK

The implementation of the PNCT introduced new possibilities for intervention, as the inclusion of tuberculosis control activities under the ESF could promote integration of services, meaning opportunity for expansion of disease control activities. For this purpose, teams must be trained to perform suspicion and diagnosis of cases; treat and supervise the drug intake; monitor contacts; keep the information system updated; perform preventive and educational activities in the community⁸.

The DOTS strategy adopted by the Ministry of Health also intends to reduce the abandonment of treatment, from five pillars: standardized and supervised treatment regimens; regular acquisition and distribution of medicines; creation of an efficient information system; search of respiratory symptoms, with laboratory support; and political commitment ⁴. This strategy has proved effective in a study in Taipei, Taiwan, reducing mortality by 40% in the patients monitored, when compared to patients who self-administered their medication⁹.

However, the impact of the strategy depends on a set of organizational measures¹⁰, both from the point of view of integration of health services and of the care for individual health, which prevents the abandonment of treatment⁴. In this sense, the ESF emerges as a priority to strengthen primary care, providing comprehensive care to users and families⁶.

Considering that the chances of abandoning the treatment are enhanced when control actions are not based in the comprehensive care, the DOT appears as a tool to form the bond between professional and patient⁴, since it can be carried out by the community health worker (CHW) or any of the ESF team members, being of vital importance to reduce the risk of transmission of the disease and contributing to its control¹¹.

Thus, the DOT needs to be performed through individual approaches, contemplating attention, responsiveness, trust and acceptance of the patient, which reinforce the importance of bonding to the development of actions and ensure a comprehensive care to users^3,12.

METHODOLOGY

This is a descriptive study of qualitative nature, carried out with 20 nurses and 30 physicians working in primary care in 15 of the 30 municipalities of the 15th Regional Health Department of Paraná. This study is linked to the project Care and Control of Tuberculosis in the state of Paraná, as this state still faces difficulty in controlling the disease, with healing rate lower than recommended by the Ministry of Health and abandonment rate higher than the acceptable¹³.

Data were collected in June and July 2013, through previously scheduled interviews carried out in the workplace, driven by the guiding question: What is your opinion on the directly observed treatment? Of the 15 cities studied, 10 have only a basic health unit, each with a specific location for the care of patients with tuberculosis. Three municipalities provide the first treatment in any of the health units and the monitoring of disease only in the outpatient clinic; one municipality has a unique outpatient clinic, which is also the gateway; and one municipality has decentralized service to all the basic units.

For the data collection, it was used content analysis, which deals with words and their meanings, describing the content of messages and allowing inferences¹⁴. There are no strict rules to make the analysis of content, but the following should be noted: pre-analysis, material exploration and processing of data¹⁴.

The initial organization of the material included the acquisition of messages and identifying them by floating reading, followed by thorough reading. Thereafter, it was initiated the coding, where the raw data are processed and aggregated in units, allowing for a description of the characteristics of the contents¹⁴. After completion of the coding, authors began the thematic analysis. After this stage, there was the categorization, based on themes found, which gave rise to the category: Directly Observed Treatment: strengths and weaknesses, from which the subcategories emerged: relevance of the DOT, reducing abandonment, difficulties and acceptance of the DOT.

The development of the study took place in accordance with the guidelines established by Resolution. 466/2012 of the National Health Council and the project was approved by the Standing Ethics Committee of the Hospital do Trabalhador/SES/PR (Opinion 311,964 / 2013). All participants signed the Informed Consent Form in two copies. For the differentiation of subjects and preservation of their identity, the following codes were used: the letter N for nurses and the letter P for physicians, followed by the serial number of the interviews.

RESULTS AND DISCUSSION

Participants interviewed were 30 health professionals, of which 20 were nurses and 10 physicians, five of whom work in municipal reference outpatient clinics and others in the ESF, with length of service ranging from 6 months to 28 years. Regarding the time of work in tuberculosis control actions, most professionals revealed that they have been inserted in these activities for more than four years. All professionals reported having monitored a suspect or confirmed case of tuberculosis.

Directly observed treatment: strengths and weaknesses

The Ministry of Health requires committed, ethic and human action from local managers, health professionals and population to achieving a quality DOT. Emerging study subcategories are analyzed below.

Relevance of the DOT

Such treatment consists in observing the intake of drugs, preferably every day or at least three times a week⁶. However, it was found that not even all professionals have put into practice this strategy due to the limited quantity of diagnosed cases, although they recognize the importance of treatment.

I find it interesting, although we have not needed not perform it in the city yet, but if we need it, it would be one of the alternatives that can work, because this untreated patient can complicate for us, so it is worth investing to treat and eliminate cases. (N2)

I think it is interesting for both parties, for the patient who is treated and for the service itself that is offering it, continuing treatment and providing guidance, seeing which aspect is good in which aspect is improving. (P1)

If you do not do the DOT, you do not know what is going on with that patient, because you end up engaging with things that are not in your area, then you need to have that time to visit a patient who is your responsibility and the DOT compels you to do this. (N12)

Reducing the therapeutic abandonment

The strategy allows the approach of professionals and users so that the health professional has the opportunity to empower the patient regarding treatment, providing an individual and dialogued education¹⁵. All health professionals recognize the importance of the DOT in reducing the abandonment rate and the bond created with the patient.

We managed to reduce the issue of abandonment of treatment of the patients to zero, currently, [...], as before, because the ODD was implemented in 2012 in the city, and from that time, we only had one patient who left last year, but it was an isolated case [...]. They realize that we are concerned about them. (N1)

Those who have closely followed the issue of tuberculosis know that the main issue is the abandonment of treatment and when you do this (DOT), you avoid it, you push them, you become more friend of the patient and they believe more in the treatment. (P4)

When we are monitoring, there is always the risk of the patient leaves, imagine the person at home, alone, taking the medication, they will not take, because taking four types of medicines is very aggressive. Sometimes I do not go and ask the CHW to go or the nursing assistant, the day I get there, they already say they not want to take, that they will not take, so if we do not monitor [...]. (N19)

The insertion of the ESF in the community facilitates the approach and the monitoring of the patient, and avoids that the patient has to commute to the service¹⁶. In this sense, the DOT performed by the ESF is of vital importance and its implementation is seen as able to reduce abandonment. From this context, the work of nurses should include two dimensions: the management, which considers the planning, organization and evaluation of service, and the care, linked to the achievement of care actions¹⁵.

Among the factors that influence the abandonment of treatment are long treatment regimens, difficult access to service, communication problems between professionals and patients, in addition to socioeconomic conditions and living habits⁵. However, to achieve success and strengthen actions to combat the disease, which remains one of the biggest challenges for the health sector, it is necessary that comprehensiveness permeates the actions and that the care to the user is strengthened⁴.

In this sense, it is necessary to establish a bond between health professionals, patients, family and community, through home visits. This is a unique moment to talk to the patient about the disease, addressing, for example, modes of transmission, duration of treatment, the importance of regularity in taking the medication, consequences of treatment abandonment and possible side effects¹⁵.

The bond requires a regular source of care, with the establishment of interpersonal ties and mutual cooperation between users and health professionals, as the users' stay in service depends on how they are received and the ability of services in solving problems^4,17. The DOT makes the organization of the care process more flexible due to host and accountability of the patient with treatment^11,18, as by knowing the uniqueness of the patient, it is possible that the professional can meet all needs presented by the patient, not focusing their activities only in drug treatment^4,19.

Difficulties

Professionals reported lack of time to carry out the DOT, which is understood as a difficulty for the smooth running of the program, since the nurse is usually overloaded, the physician cannot meet all the demand, not all teams have enough CHWs and when there is, they are not always qualified for that function.

We do not do due to lack of time [...] we spend about 40 minutes only in a supervised dose, and in a period of four hours if we spend 40 minutes, it is a long time, this is not a time you lose, it is a time that you are investing, but sometimes we do not have that time, and sometimes we do not have employees to do this. (N3)

It is a very good strategy, and a difficulty that sometimes we may have is to have a professional, because sometimes it might be sent a person who does not have the necessary qualification. (P3)

Maybe a little difficult on weekends, a bit difficult to ask for the CHW, they often find it difficult to approach the patient, the family. (P2)

The units need to have structure to meet these patients, especially the structure of human resources, to have a professional available to go there in an appropriate time for the patient, who may receive this professional to take the medicines. (N11)

However, for a dialogue-based approach, with patient empowerment, health professionals must be able to transmit not only knowledge about the disease, but also confidence and awareness about the importance of treatment. However, the qualification of health professionals is insufficient, and there is need for establishing a permanent training policy so that teams provide care for tuberculosis cases, which will reflect in an improvement of care²⁰. Educational activities should be developed by all professionals, both during the consultation at the clinic, and in the home visits, confirming the comprehensiveness of the care provided^19,20.

The CHW, besides having a prominent role in the identification of respiratory symptoms in their coverage area, is one of the professionals who can develop the DOT⁸, as they come from the community in which they work and as part of the health team, becomes the link between the community and the service²¹. From the actions planned by the team, in agreement with the patient, so that the CHW is the doer of the DOT, they must be prepared for such a role, providing guidance on the disease⁸.

The preparation of the CHW to guide the community and conduct the DOT successfully is a responsibility of the health team, especially nurses and doctors. A study carried out in Ribeirão Preto revealed that in Brazil the knowledge of the CHW on tuberculosis is incipient, only allowing them to develop specific, isolated and incongruous actions, whereas internationally the work of CHW has increased the population's access to health services, the acceptability and adherence to treatment²¹. In this regard, it is stressed by the professionals, besides the lack of human resources, training and time, the difficulty with transportation to get to the patient's home.

I have to go with my car to deliver the drug to the patient, what kind of support does they give? None! [Anger] [...] they want the team to do it, but do not give structure, or car, or professional, nothing. (N20)

I think they should give more conditions to the professional that goes in the houses, because it is almost priesthood. (P6)

So we realize that certain weaknesses lead to improper functioning of the strategy, undermining the implementation of activities and hindering the process of decentralization, such as work overload, lack of human resources and the fragmented view of the professionals involved.

It is also worth mentioning that the team must be integrated to achieve progress in tuberculosis control, so that the work process is reorganized, with a view to collective action. However, it is essential that the municipal management properly plays its role in supporting the team's actions and providing institutional arrangements consistent with the needs arising in tuberculosis control²¹.

Therefore, it is unacceptable the lack of official transport to monitor cases of DOT¹⁵. To change this reality, municipalities need to keep updated the registration of cases diagnosed and in treatment, and with this information, request to the Ministry of Health funds for the purchase of vehicles used exclusively for the DOT¹⁵. However, some professionals have questioned the realization of the DOT every day, claiming that there are patients who do not require such treatment, or the limitation of human resources does not allow the development of this strategy.

Sometimes this daily monitoring is not necessary because there are patients who have knowledge of the disease and can perform the treatment without major problems and we do not have to go there every day, because we have to assign a CHW exclusively for this, at different times, which complicates our work, but we end up doing, coming to terms with the patient and with the CHWs and performing in all patients. (N5)

I do not think we need to go every day, because we go and the patient has already taken the drug, we are doing it, but I see some failures in this regard. (N14)

The patient needs to be responsible for their treatment too, not only the team and the health unit. (N20)

From this vision, health professionals indicate this strategy as a way to approach the community demands, but state that not all patients require that the DOT is implemented. Of course, to identify those who do not need it, professionals need to know the patient's characteristics, their families and the context in which they are inserted. This differentiation is important because in this way, professionals can dedicate more to implement the DOT with the rebel patients, drug users, street dwellers, among other stigmatized populations³.

Acceptance of the DOT

Patients, in the view of professionals, usually receive the DOT well, realizing greater care and concern of the team with their health conditions, and create or strengthen the bond and friendship between them.

It is not easy for health professionals, because we have a million things to do, it is not easy, but it is important for the patient, because they ask all their doubts when we do the supervised dose. (N16)

It gives more tranquility even to the patient [...], but there are advantages and disadvantages, professionals need to be able, but it is a relationship with the patient. (P6)

Today we see that it is easier, we see the trust that the patient has, and we see the patient better each day with the DOT, so we found difficult to implement at first, but today [...] we have no problem, it is a bond that you get with the patient. (N8)

Health professionals believe that the acceptance of the patient is mainly due to the bond constructed and from the moment the patient understands the need and importance of DOT, the adherence becomes easier. The approach between patients and professionals and the improvement arising with treatment contribute to the strengthening of relations of trust and commitment to the therapeutic process¹⁷. For professionals, the DOT is an opportunity to be close to the community, but for this, it is necessary to point out to users the importance of treatment and maintain good communication³. However, it was also reported rejection of a patient because he perceived the DOT as a strategy used for patients unable to take care of themselves alone.

This patient we have now, when you talk to him that we have to give the medicine, he says he is not a child, he gets rebellious, he feels angry, he fights, [...] he is taking the medicine, when we get there he has already taken it, and we know that he is taking properly because if he was not taking the medicine right, he would not be better. (N15)

Some patients do not accept the DOT for fear of prejudice and discrimination that may suffer to share the diagnosis with others. A study in Rio de Janeiro found that patients would like to opt for this type of treatment, but see the DOT as a form of submission and punishment for the irresponsibility of others who did not complete the treatment earlier ³. The Ministry of Health recommends that all patients receive the DOT¹⁵, however, in addition to professionals reporting that not everyone needs it, some patients feel submissive and punished by this imposition of treatment.

CONCLUSION

This study points out problems in the health system and in the organization of services. However, it stresses the importance of the ESF in the DOT, which can reduce the transmission and change the landscape of the disease in the country. Thus, it is necessary to reflect on the role of the nurse as a critic professional, emphasizing the importance of discussing the issue and asking improvements to the manager, aiming at a comprehensive care.

It is also highlighted the need for investment in training professionals about the disease, hiring new professionals for the ESF, material resources and transportation to perform the DOT, allowing that the implementation of the strategy is complete and achieve satisfactory results in reducing rates of disease. It is hoped that this study can contribute in the management actions of services and in reorienting tuberculosis control actions.

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