title: Operational research on tuberculosis control program in East Timor
title: transdisciplinary research documenting the introduction of the DOTS strategy and investigating factors contributing to patient's adherence to tuberculosis treatment
titleType: Subtitle
Creators: name: Martins, Nelson
Publisher: name: Charles Darwin University
Year: 2006

description: Globally, the number of tuberculosis (TB) cases continues to rise and to cause more deaths, especially in resource poor countries. The World Health Organization (WHO) strategy known as Directly Observed Treatment Short-course (DOTS) strategy has been recommended to be adopted as the gold standard health system response to fight TB in these settings, but it has faced huge constraints in its implementation because of the lack of both financial and human resources. There remains a tendency for a one size fits all, with little scope for adaptation to find local solutions to local problems. The DOTS strategy was introduced to East Timor in 1995. The nature of the culture, geography and political history of the country and its people combined with the very high burden of TB (see Chapter 1) offers an interesting opportunity for a series of inter-linked case studies examining TB control issues. These include the nature of TB control programs during the conflict and post-conflict situations and the cultural and health system barriers and enabling factors for treatment compliance in this setting. This operational research study was conducted to explore these issues and to answer some of the key research questions identified by the National TB Control Program. This thesis was based on: i). An extensive review of the literature on the issues of TB, post-conflict health service reconstruction and East Timor; ii). The findings from two qualitative research studies; and iii). The findings from two quantitative studies. The aims of the study and methodology used are discussed in greater detail in Chapter-2. East Timor was as sovereign nation prior to the arrival of Europeans in the 16th Century. The country was colonized by the Portuguese for more than 450 years and was under Indonesian occupation for 24 years from 1975, finally gaining its full independence in May 2002. Tuberculosis has been recognized as a problem and claimed many lives during the time of colonial and foreign occupation. It was not until 1995, however, that the local authorities and local leaders, and was called for more serious intervention. The response was positive with the establishment of DOTS pilot in some government clinics and the establishment church based TB control program. But, the programs were destroyed following the September 1999 violence by pro-Jakarta militia. Soon after that, a comprehensive national TB program was established. The history, politics, health system and TB issues in East Timor are comprehensively discussed in Chapter-3. Study–I (Chapter 4) is a descriptive epidemiological study which discusses how tuberculosis control has flourished despite chronic low tension conflict (1995-99), a brief but intense high level conflict (1999) and post-conflict reconstruction (2000-2004). The study found that, before 1999, a non-government TB control program was established in several districts and showed optimistic results. External donor funds, technical assistance and the local strategies for TB treatment compliance were key components. In 1999, conflict led to complete disruption of the program. Within four months a National TB Control Program (NTP) was established from the non-government program in collaboration with other partners. The notification rate of 108 sputum smear positive pulmonary TB cases per 100,000 populations in 2004 was the highest in the region and reflects high population coverage. The cure rate of 81% is close to achieving the WHO target. Key components of the NTP-TL which contributed to this success are: i) the inclusive nature of involving various parties in one unifying TB programs, ii) the ongoing assistance from international consultants ; iii) constant training and supervision; iv) commitment from local staff. Study-II (Chapter 5) is a stakeholder analysis designed to examine in greater detail the reasons for the successful re-establishment of the NTP during the emergency period which followed the violent of political conflict of September 1999. Twenty four participants who are currently or were previously involved in the TB program were interviewed for this study. These include TB nurses, international consultants, NTP directors, head of WHO, and senior minister of health staff. The existing local structure ix and experience, the commitment to establish an effective program and the willingness of international advisers and local counterparts to be flexible in their approach, were important factors. The major impediments, including mass population displacement, lack of infrastructure, and the competing interests of organisations working in the health sector were addressed through a cooperation, coordination and collaboration between local and international partners. The TB Program continues to operate in all districts with high notification rates, although a lack of ownership by government health workers, low compliance and high default rate remain challenges. Study-III (Chapter 6) discussed the finding of the first ethnographic study employed in the field of TB control in East Timor. Following on from the key issues identified in the two previous studies, this study was designed to understand the reason behind high default rates in an urban and a rural district. Semi structured interviews were conducted with 28 participants (22 patients and six TB nurses) and Focus Group Discussion (FGD) were conduct with community members in seven villages (three urban and four rural). The findings reveal the nurses have good knowledge about TB and high commitment to the DOTS strategy. In contrast, defaulter patients and community members possess a low level of knowledge and awareness of TB. Having good knowledge of the disease, the right interpretation of cure, and the provision of food incentives were important factors for patients to complete TB treatment. Obstacles for TB treatment completion included a preference for traditional medicine, economic difficulties and geographic remoteness. Study-IV (Chapter 7) present the finding from the first randomized control trial conducted in East Timor. The study was designed to assess the effectiveness of food incentives to enhance TB treatment compliance. Newly diagnosed adult TB patients were randomly assigned into two groups. One group (intervention: N=139) received food and the second group (N=131) received nutritional advice (placebo). An interim analysis on 168 patients (Intervention N=83; Control N=85) is presented here. The study found; the majority of TB patients have lower socio-economic status, but have good access to TB services. The baseline Body Mass Index (BMI) was 16.8 before and 18.5 after the provision of food and anti TB treatment. The provision of anti-TB drugs has significantly alleviation most TB symptoms. Treatment success rate was 81% in the intervention group compared to 78% in the Control group [Differences: 95% CI: 3 (-9, 15)]. The food intervention however showed no impact in improvement clinical symptom, treatment outcome and treatment compliance. There are possible several explanations for the negative results for food in this study. Firstly: due to the strict selection of participants for the study, we might have ruled out most patients with certain attitudes for non-compliance with the treatment. Secondly, measurement bias might also contribute to this negative result. Perhaps the true impact of food on treatment outcome and compliance should be measured differently. We lacked the required equipment on site to measure potential immunological or biological determinants of an effect of the food intervention. Lastly, the data presented in this paper is not the complete sample enrolled in the study, according to our sample size calculation. It is possible therefore that it does not have sufficient power to represent the true finding from the study. xi The thesis concludes with overall conclusion and recommendations arising from this body of work aimed at strengthening TB control in East Timor and those TB programs operating in similar settings in other countries (Chapter 8). The key conclusions are: 1. DOTS programs, with slight modification to fit local conditions, can be successfully introduced during low tension conflict and post conflict situations; 2. Coordination, cooperation, collaboration and flexibility are key components for a successful re-establishment of TB services after major conflict; 3. TB program understanding of community perceptions of curability of TB and the provision of acceptable incentives can be key elements for patients to complete their TB treatment. Strong belief in traditional medicine and geographical remoteness can lead patients to default from their TB treatment. 4 Food incentives showed no impact in improvement treatment outcome, clinical outcome and treatment compliance in lower socio-economic class with good access to TB services in one urban setting. Repeat clinical trials in other settings, are needed to examine the impact of food to improve clinical outcome for undernourished TB patients. Alternative study designs may be more appropriate to examine the impact of food incentives in the context of the TB program management.