Research Article: Is directly observed tuberculosis treatment strategy patient-centered? A mixed method study in Addis Ababa, Ethiopia

Date Published: August 1, 2017

Publisher: Public Library of Science

Author(s): Belete Getahun, Zethu Zerish Nkosi, Madhukar Pai.


The directly observed treatment, short course (DOTS) strategy has been considered as an efficacious approach for better tuberculosis (TB) treatment adherence and outcome. However, its level of patient centerdness has not been studied and documented well. Hence, the study aimed to determine the level of patient centeredness’ of the DOTS.

The study used explanatory sequential mixed method design in Addis Ababa, Ethiopia. The study employed an interviewer-administered questionnaire with 601 patients with TB, focus group discussions with 23 TB experts, and telephonic-interview with 25 persons lost to follow-up from TB treatment. Descriptive and multivariable analyses carried out for the quantitative data while thematic analysis was used for the qualitative data.

Forty percent of patients with TB had not received patient-centered TB care (PC-TB care) with DOTS. Male gender (AOR = 0.45, 95% CI 0.3, 0.7), good communication (AOR = 3.2, 95%CI 1.6, 6.1), and health care providers as a treatment supporter (AOR = 3.4, 95% CI 2.1, 5.48) had significant associations with PC-TB care. All persons lost to follow-up and TB experts perceived that DOTS is merely patient-centered. The identified categories were patient preferences, treatment supporter choice, integration of DOTS with nutritional support, mental health, and transport services, provider’s commitment and communication skills.

DOTS is limited to provide patient-centered TB care. Hence, DOTS needs a model that enhances effectiveness towards patient centeredness of TB care.

Partial Text

In the mid-1990s, World Health Organization (WHO) developed and recommended directly observed treatment, short course (DOTS) for the treatment of TB. The DOTS strategy encompasses political and administrative commitment, case detection primarily by microscopic examination of sputum of patients presented to health facilities, standardized short course chemotherapy given under direct observation, adequate supply of good quality drugs and systematic monitoring for every patient diagnosed [1]. The DOTS has been considered as a cornerstone and efficacious for better treatment adherence of TB control programme in developing countries [2–4]. Moreover, DOTS is perceived to be associated with decreased probability of acquiring and transmitting drug resistance [5], and improved treatment success rate [6].

The study used overarched WHO health care policy framework to determine the level of patient centeredness of DOTS. As a result, the study indicates that, although feeling across dimensions was not similar, overall perceived PC-TB care is 60% among patients with TB who were on follow-up. Apart from this, none of the lost to follow-up persons perceived as they received PC-TB care. In addition, DOTS is rarely patient-centered in the view of TB experts’. However, in TB control strategy provision of PC-TB care was conceptualized at the introduction of DOTS [24], emphasized as a required component in stop TB strategy (2006-2015) and it is one of the core pillars to end TB epidemic [25].

DOTS is limited to provide comprehensive PC-TB care even if it has fewer components of PCC for patients with TB particularly at the start of the TB treatment. DOTS lack to include many of PCC components such as keeping patients’ preferences and treatment supporter choice, provision with respect and value of patient with TB, and integration of allied services such as adequate information provision and counselling, nutritional support, mental health, and transport services. Further, it requires HCPs’ commitment, communication skill and strong support to the patient to cope with TB. Hence, a PC-TB care model that considers the important components to provide PC-TB care for patients with TB is required.




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